Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;Epub Jun 1.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.
Connor DM, Narayana S, Dhaliwal G. Diagnosis (Berl). 2022;9:265-273.
Teaching clinical reasoning to medical students is a key strategy for reducing diagnostic errors. This paper describes a new longitudinal clinical reasoning curriculum taught in a US medical school’s first and second year of medical training. Students reported high self-efficacy after completing the curriculum; however, a competency audit revealed room for improvement in including system-related aspects of care.
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.
Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
Kostick-Quenet KM, Cohen IG, Gerke S, et al. J Law Med Ethics. 2022;50:92-100.
Biases in decision support technologies precipitate racial inequities. This commentary discusses how algorithms in machine learning contribute to inaccuracies in the care of persons of color and the displaced. Legal actions to mitigate racial biases in decision making programs and implementation steps toward improvement are discussed.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;Epub Apr 28.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Davy A, Borycki EM. Stud Health Technol Inform. 2022;290:438-441.
Dashboards provide a way to display patient safety data (e.g., medication safety) in real time. This narrative review and SWOT (strengths, weaknesses, opportunities, threats) of existing patient safety dashboards can form the basis for developing future dashboards.
Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796.
Surveys are recognized tools to inform hospitals of the current status of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Hospital Survey on Patient Safety Culture Comparative Database data collection process. The deadline for submitting comments on this notification is August 2, 2022.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
This annual Patient Safety Reporting Program (PSRP) publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2021 data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon.
Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.
When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.
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