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Health Care Futures. June-July 2022.

Strategies to educate new health professionals in patient safety and quality improvement can ensure commitment to improvement work. This fellowship will help learners understand the evolution of patient safety and develop skills in quality improvement and human factors engineering. The application period is now closed.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.
Heed J, Klein S, Slee A, et al. Br J Clin Pharmacol. 2022;88:3351-3359.
Hospitals in the US can evaluate the safety of their computerized provider order entry using a simulation tool such as the one provided by the Leapfrog Group. This study developed a similar simulation tool for use in the UK. Study participants rated 178 clinical scenarios for likelihood of occurrence, level of associated harm, and likelihood of harm. One hundred and thirty-one extreme or high-risk prescribing scenarios were developed and will be used to create the evaluation tool.

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.1 Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.2 Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.2

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).1 Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.

Obtaining a best possible medication history is the cornerstone of medication reconciliation but can be resource-intensive. This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. 

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

The AHRQ Medical Office Survey on Patient Safety Culture  is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.
Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.
Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool. 
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;Epub Mar 22.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
Medication errors are common among older adults discharged to long-term care facilities. Researchers reviewed medication discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted or re-admitted residents had at least one medication discrepancy discovered at nursing home intake. Residents who were prescribed 14 or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest risk for discrepancies. Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance of medication reconciliation for residents with respiratory conditions or pain.
Brierley-Jones L, Ramsey L, Canvin K, et al. Res Involv Engagem. 2022;8:8.
Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.
Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.
Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.
Dieckmann P, Tulloch S, Dalgaard AE, et al. BMC Health Serv Res. 2022;22:307.
When staff feel psychologically safe, they are more likely to speak up about safety concerns. This study sought to explore the link between psychological safety and improvement work, and whether an existing model captures all the relevant ‘antecedents’ and ‘consequences’ of psychological safety.
Furlan L, Francesco PD, Costantino G, et al. J Intern Med. 2022;291:397-407.
Overtreatment and overuse can have unanticipated consequences, ranging from patient anxiety while awaiting test results to medical complications. The authors identify several factors that can contribute to patient overtreatment (fear of uncertainty, cognitive bias, applying low-quality evidence, and overfocusing on diagnosis). Interventions to overcome these issues include educating clinicians that uncertainty is a part of medicine and shifting to a focus on patient-centered management rather than focusing on identifying a diagnosis.
Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.
Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.
Gonzalez-Smith J, Shen H, Singletary E, et al. NEJM Catalyst. 2022;3.
Clinical decision support (CDS) helps clinicians select appropriate medications, arrive at a correct diagnosis, and improve intraoperative decision making. Through interviews with health system executives, clinicians, and artificial intelligence (AI) experts, this study presents multiple perspectives on selection and adoption of AI-CDS in healthcare. Four emerging trends are presented: (1) AI must solve a priority problem; (2) the tool must be tested with the health system’s patient population; (3) it should generate a positive return on investment; and (4) it should be implemented efficiently and effectively.