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Alper E, O'Malley TA, Greenwald J. UpToDate. August 18, 2022.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.
Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Diaz MCG, Dawson K. Am J Med Qual. 2020;35:474-478.
Communication and shared mental models are key elements to effective teamwork. This study explored whether simulation-based closed-loop communication training would improve staff perceptions of communication ability and decrease medical errors. Increases in perception of closed-loop communication ability were sustained one-month after training. A retrospective chart review of all emergency severity index (ESI) level 1 patients (n=9) seen in the 4-months pre- and post-training showed a reduction in medical errors (89% to 56%, respectively).
Haydar B, Baetzel A, Elliott A, et al. Anesth Analg. 2020;131:1135-1145.
This systematic review was undertaken to provide clear enumeration of adverse events that have occurred during intrahospital transport of critically ill children, risk factors for those events, and guidance for event prevention to clinicians who may not be fully aware of the risks of transport. The recommendations for reducing adverse events frequently given in the 40 articles that met the inclusion criteria (reflecting 4104 children transported) included: use of checklists and improved double-checks (of, e.g., equipment before transport).
Dewar ZE, Yurkonis T, Attia M. Medicine (Baltimore). 2019;98:e17459.
Poor communication and handoffs between providers have been linked to adverse events.  The implementation of a standardized hand-off bundle modeled on the I-PASS tool (incorporating illness severity, patient summary, action list, situational awareness, and synthesis by receiver) in an inpatient family medicine service resulted in a significant reduction in medical errors.
Simpkin AL, Murphy Z, Armstrong KA. Diagnosis (Berl). 2019;6:269-276.
Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.
Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.
Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2019;38:44-54.
This pre–post study examined the implementation of AHRQ's TeamSTEPPS training program. Investigators found that the intervention had positive effects on staff ratings of teamwork and patient satisfaction, and these improvements persisted for one year.
Schwarz CM, Hoffmann M, Schwarz P, et al. BMC Health Serv Res. 2019;19:158.
Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2019;15:10794.
Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2018;14:10736.
The I-PASS structured handoff tool intends to reduce errors and preventable adverse events. This article describes the development of the I-PASS Mentored Implementation Guide. The guide was considered by I-PASS sites essential, particularly the sections on the I-PASS curriculum and handoff observations.
Artis KA, Bordley J, Mohan V, et al. Crit Care Med. 2019;47:403-409.
Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.
Shenvi EC, Feupe SF, Yang H, et al. Diagnosis (Berl). 2018;5:235-242.
Seeking feedback on patient outcomes after a patient handoff takes place may provide useful learning for the provider who initially cared for the patient and inform future clinical decision-making. In this mixed-methods study, residents identified both a lack of time and inadequate systems for tracking patients as significant barriers to learning from the outcomes of patients they had handed over to other teams.
Link T. AORN J. 2018;108:165-177.
Although team development has received increased attention in health care, miscommunications that affect patient safety continue to occur. This commentary reviews factors that contribute to poor communication behaviors among perioperative nurses and summarizes guidance on how to improve team communication, such as use of standardized checklists and briefings.
Molloy MA, Cary MP, Brennan-Cook J, et al. Home Healthc Now. 2018;36:225-231.
Patient utilization of home care is expected to increase with advances in medical care and health technologies. This commentary presents simulation as a promising tool to develop and assess home care staff skills to improve transitions from acute care to home health care.