Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.

Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.

Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, production pressures, and fatigue. This commentary reviews handover behaviors, tools that can enhance handover quality, and how to engage patients and families as information sources during handovers.

The use of readmission rates as a metric of care quality remains controversial, as United States–based studies have shown that only a minority of readmissions are preventable. This prospective cohort study, conducted in 4 European countries, sought to evaluate the preventability of 30-day readmissions after hospitalization from both clinician and patient perspectives. Investigators found that 27.8% of readmissions were considered predictable (by the majority of those interviewed) and 14.4% were considered preventable. However, there was little consensus between physicians, nurses, patients, and caregivers about whether readmissions were preventable and why readmissions occurred. The only factor that consistently predicted readmission risk was if patients reported not feeling ready to go home on the day of discharge. This study adds to the literature questioning the utility of readmission rates as a measure of the quality of care.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Incident reporting systems and root cause analyses remain the main mechanisms by which adverse events are identified and reviewed. This study sought to determine whether more localized, unit-based incident reporting systems might provide better insight into how patient safety incidents vary across hospital units and services than hospital or national level reporting systems. While similar safety issues and root causes were identified across all units and services, medication safety issues were more common on internal medicine and surgical units. On the other hand, collaboration issues were more frequent in emergency medicine units. These findings suggest that localized safety reporting systems might provide information that could promote improvement efforts.

Rapid response teams have been championed as a strategy to improve hospital outcomes. However, evidence regarding their effectiveness is mixed, and rapid response teams remain controversial. In this pre-post study across multiple hospitals, the combined incidence of in-hospital death, cardiopulmonary arrest, and unplanned intensive care unit admission decreased following the introduction of rapid response teams compared to the pre-implementation time period. Although this study design does not offer definitive evidence that rapid response was the cause of the declining event rate, it does add support for the call in the National Patient Safety Goal to implement rapid response more widely. Barriers to rapid response team implementation include personnel costs as well as existing culture which may lead to reluctance to activate a rapid response.

Compared with non-elderly patients, geriatric patients in this Dutch study were more likely to experience medication errors and adverse events during hospitalization.

Although nurses and physicians mostly judged the care they provided to patients in the hours preceding a cardiopulmonary arrest or unplanned transfer to the intensive care unit as good, an independent expert panel was less charitable, pointing to frequent delays in recognition of deterioration.

… Jt Comm J Qual Patient Saf … Nearly 80% of Dutch hospitals have … and function of the team varies across hospitals. … Ludikhuize J; Hamming A; de Jonge E; Fikkers BG. …