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Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Admitted to the trauma service following severe injuries, a man is transferred to the ICU for mechanical ventilation. After 6 weeks of hospitalization, the patient's initial shoulder injury progressed to involve significantly limited mobility and pain, prompting concern that physical therapy should have been initiated earlier.
Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-8.
Communication between hospital-based and outpatient physicians is often suboptimal, and is thought to play a role in precipitating adverse events after discharge and rehospitalizations. However, this case-control study found that performance of several aspects of discharge communication—including medication reconciliation, discharge summary completion and quality, and patient education—did not decrease the risk of readmission. Other studies of specific discharge interventions, such as arranging outpatient follow-up or pharmacist review of medications, have also not affected readmission rates, meaning that preventable readmissions may only be reduced through more comprehensive (and resource-intensive) programs.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Sentinel Event Alert. 2008;41:1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Kripalani S, Jackson AT, Schnipper JL, et al. J Hosp Med. 2007;2:314-23.
This article reviews key challenges in providing safe transitions from hospital to home, including discontinuity between inpatient and outpatient physicians, medication regimen changes, and complicated discharge instructions. The authors also discuss strategies to prevent medical errors in the postdischarge period.
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
Frush KS, Hohenhaus SM eds. Clin Pediatr Emerg Med. 2006;7(4):213-283.
This special issue provides 11 articles on various aspects of ensuring safety in pediatric emergency care, including the use of rapid response teams and family involvement in care.
With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.
This study followed more than 2600 discharged patients from two hospitalist services to capture the number and types of test results that required intervention. Investigators discovered that nearly 40% of patients enrolled had a pending lab or radiology test with 9% requiring action. Discussion also includes survey findings from inpatient providers, which demonstrated poor awareness of pending studies and general dissatisfaction with current systems to manage test follow-up. The authors conclude that future efforts to reduce these preventable errors in discharge follow-up require improved systems for retrieving tests after discharge and better communication between inpatient and outpatient providers.