Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).

Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.

Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting. 

Patient falls are an ongoing source of preventable harm, yet mitigating the fall risk of inpatients remains challenging. Conducted across three academic medical centers, this study evaluated the impact of a fall-prevention toolkit (Fall Tailoring Interventions for Patient Safety (Fall TIPS)). The Fall TIPS toolkit supports nurses in providing tailored, fall-prevention intervention and engages patients and families in fall prevention efforts. After implementation of Fall TIPS toolkit, there was a 15% reduction in falls and a 35% reduction in falls with injuries.

This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.

The Fall TIPS (Tailoring Interventions for Patient Safety) program has been shown to be effective in preventing inpatient falls through formal risk assessment and tailored patient care plans. This study demonstrated that patients with access to the Fall TIPS program are more engaged and feel more confident in their ability to prevent falls than those who were not exposed to the program.

… KO, Rozenblum R, Dalal AK, Benneyan J, Bates DW, Dykes PC. …

Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

Researchers sought to assess the effectiveness of a fall prevention toolkit in engaging patients and families in fall prevention. They used several different modalities to foster engagement including an electronic medical record version, a paper version, and a version displayed on the patient's bedside monitor. All three methods were effective.

In this cluster-randomized trial, researchers examined the impact of an automated phone call with the option of transfer to a live pharmacist on detecting potential adverse drug events for patients newly started on medications for certain conditions in the primary care setting. Patients receiving the intervention were more likely to have medications stopped with documentation reflecting adverse effects.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

When patients and caregivers report adverse events, they may identify unique issues that other reporting systems do not capture. The authors propose adjustments to AHRQ's Common Formats for safety event reporting that allow patients and caregivers to more effectively report adverse events. An Annual Perspective emphasized the value of patient adverse event reporting in larger efforts to engage patients in their safety.

Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to improve safety.

Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.

Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.