Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

… J Gen Intern Med … COVID-19 ushered in new diagnostic … in hospitalized patients under investigation for COVID-19. J Gen Intern Med. Epub 2023 Mar 23.  …

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.

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%).

… J Hosp Med … I-PASS is a structured handoff tool to enhance … prospective effectiveness implementation study. J Hosp Med . Epub 2022 Nov 3. doi: 10.1002/jhm.12979 …

Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.

Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.

Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

… in unintentional mediation discrepancies over time. … Schnipper JL, Reyes Nieva H, Mallouk M, et al. Effects of a …

… J Patient Saf … Harm from opioids is a widely recognized … on hospitalized previously opioid-free surgical patients. J Patient Saf. 2021;17(2):e76-e83. …

… J Hosp Med … Based on a survey of hospital medicine groups at … pandemic: a national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488. Epub 2020/08/18. …

… J Racial Ethn Health Disparities … This study recruited … difference in incidence by race. … Costello WG, Zhang L, Schnipper J, et al. Post-discharge adverse events among …

… Am J Health Syst Pharm … This article reports mixed results of a … Quality Improvement Study (R-VA-MARQUIS).  Am J Health Syst Pharm . 2020;77(2):128–137. …

… J Am Med Inform Assoc … In 2014, the Agency for Healthcare … time through EHR integration.   … Businger AC, Fuller TE, Schnipper JL, Rossetti SC, Schnock KO, Rozenblum R, Dalal AK, Benneyan J, Bates DW, Dykes PC. …

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.

Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.

The I-PASS structured handoff tool intends to reduce errors and preventable adverse events. This article describes the development of the I-PASS Mentored Implementation Guide. The guide was considered by I-PASS sites essential, particularly the sections on the I-PASS curriculum and handoff observations.