Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.
The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).
Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.
The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.
Patient safety is a concern throughout the entire process of care from admission to discharge. This article highlights the role of risk managers to assure that patients return to a home environment that can enable their safe recovery whether the discharge is advised or not.
Khoong EC, Cherian R, Rivadeneira NA, et al. Health Aff (Millwood). 2018;37:1760-1769.
California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.
Home healthcare is an increasingly viable option for patients who requires the complex care skills of caregivers. This commentary discusses the Caregiver Advise, Record, Enable (CARE) Act as a policy lever to ensure family caregivers have the training they need to provide safe care.
Sasso L, Bagnasco A, Aleo G, et al. BMJ Qual Saf. 2017;26:929-932.
Multiple factors in the hospital environment influence the incidence of missed nursing care. This commentary describes strategies to address these errors of omission, including changing mental models to recognize the financial benefit of increasing staffing levels to improve patient safety.
Arbaje AI, Werner NE, Kasda EM, et al. J Patient Saf. 2020;16:52-57.
Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.
Stall NM, Fischer HD, Wu F, et al. Medicine (Baltimore). 2015;94:e899.
This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.
In response to a recent investigation raising concerns about inaccurate reporting of wait-time data, this commentary relates barriers to improving patient safety, such as overuse of performance measures. The authors describe approaches to augment safety, such as narrowing down performance measures to address the most significant concerns and engaging private health care organizations in improvement projects.
Gale BD, Bissett-Siegel DP, Davidson SJ, et al. J Am Coll Radiol. 2011;8:776-9.
This analysis of closed malpractice claims over an 18-year period identified more than 300 cases of malpractice attributable to failure to communicate test results in a timely fashion. The incidence of such errors appeared to increase over the time period studied.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-36.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.
Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-9.
This cost analysis of the 2011 duty hour regulations for resident physicians demonstrates that the regulations will almost certainly result in increased costs for teaching hospitals, unless preventable adverse events decline substantially after the new regulations are implemented.
Foy R, Hempel S, Rubenstein L, et al. Ann Intern Med. 2010;152:247-58.
This meta-analysis found that interactive communication between collaborating primary care providers and specialists (psychiatrists and endocrinologists in this study) is associated with improved patient outcomes. The interactive communication methods included joint consultations, scheduled phone discussions, and shared documentation, with the authors suggesting a need for changes in reimbursement models to support such interventions.
Cheung DS, Kelly JJ, Beach C, et al. Ann Emerg Med. 2010;55:171-80.
Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.
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