Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.

During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

Elements of critical care can influence the reliability of diagnosis, teamwork, and care delivery. This commentary recommends areas for research to reduce diagnostic error in the intensive care unit. The authors highlight the need for intensivist involvement to define distinct roles and actions in their specialty for diagnostic improvement.

A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.

To determine the impact of the Comprehensive Unit-Based Safety Program (CUSP) on patient safety, this study compared intensive care units participating in the program with units not participating. Although safety culture improved in units with CUSP implementation, the intervention did not reduce incidence of central line–associated bloodstream infections. These findings demonstrate that teamwork training approaches, while helpful, may not be sufficient to augment patient outcomes. Further study characterizing sites that improved versus those that did not may elucidate facilitators and barriers to achieving patient safety goals.

Patients in the intensive care unit (ICU) are particularly vulnerable to medical errors, and the inherently stressful nature of the work may adversely affect providers as well. A prior study found a high incidence of burnout in neonatal ICU staff and demonstrated that increased rates of burnout were associated with worsened perceived safety culture. This prospective observational study, conducted in 31 ICUs in France, sought to examine the relationship between burnout, depression, safety culture, and adverse events. The investigators found that more than 30% of staff met objective criteria for being burned out, and more than 15% met clinical criteria for depression, which was an independent risk factor for medical errors. Overall safety culture was only fair, and better perceived safety culture did not attenuate the relationship between depression and medical errors. This study adds support for the belief that enhancing resilience in clinicians is a cornerstone of safety efforts, as articulated by safety expert Dr. J. Bryan Sexton in a past AHRQ WebM&M interview.

Formal transition programs for patients being discharged from the intensive care unit (ICU) to general wards, which generally involved proactive surveillance by a nurse or physician, were associated with a decreased risk of readmission to the ICU.

Surgical specialists report frequently experiencing conflict with intensive care unit physicians and nurses regarding goals of care when patients experience poor postoperative outcomes.

This Saudi Arabian study describes a rapid response team implementation consisting of an intensive care physician, critical care nurse, and respiratory therapist. Over a 3-year period, the introduction of the team was associated with fewer cardiopulmonary arrests and improved hospital mortality.

This commentary discusses areas of risk in the intensive care unit along with interventions to mitigate them, including isolation precautions to lower infection rates and staffing intensivists to improve patient outcomes.

Exploring the impact of 24-hour intensivist coverage on patient safety, this piece advocates for research to understand how a nocturnal intensivist program can influence staffing needs and medical education.

This survey of Canadian intensive care units found that larger units and units directed by full-time intensivists had more positive safety culture scores.

This commentary describes a formal assessment, consultation, and follow-up initiative led by a clinical nurse specialist to improve patient transfer from the intensive care unit (ICU) to medical wards.