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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.

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.
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).
Achilleos M, McEwen J, Hoesly M, et al. Am J Health Syst Pharm. 2020;77.
Pharmacists are critical to ensuring safe transitions between acute care and skilled nursing facilities (SNFs). This retrospective study evaluated the frequency of missed doses of high-risk medications after hospital-to-SNF transfers and found that 60% of first doses of high-risk medications were given after the scheduled administration time. After implementation of a medication order process including pharmacist-led medication reconciliation, the average delay in medication administration decreased significantly. 
Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.

Latzke M, Schiffinger M, Zellhofer D, et al.  Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care [Epub 2017 Nov 28]. Health Care Manage Rev. 2020;45(1):32-40. doi: 10.1097/hmr.0000000000000188.

This study examined the impact of safety climate and team processes on patient safety events occurring during intrahospital transport. The authors analyzed 858 transfers occurring over a 4-week period and assessedsafety climate and team processes using standardized scales. After controlling for transport-, staff-, and ICU-related variables, the authors found that safety climate, team processes and transport training were associated with adverse events during intrahospital transport.
McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46:341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
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.
Jones D, Baldwin I, McIntyre T, et al. Qual Saf Health Care. 2006;15:427-32.
Medical emergency teams (METs, also known as rapid response teams) are being widely implemented in U.S. hospitals. Although their effectiveness in preventing adverse patient outcomes is uncertain, a major proposed benefit of such teams is to provide support for nursing staff. This study, conducted at an Australian hospital with a long-standing MET, surveyed ward nurses to determine if they understood the appropriate reasons to call the MET and evaluate if they felt the MET improved patient safety. Nearly all nurses felt the team helped provide more effective care for patients and helped educate nurses in caring for acutely ill patients. Nurses did not feel that they would be criticized for calling the MET. Despite the presence of objective criteria (eg, vital sign abnormalities) for calling the MET, most nurses preferred to use their clinical judgment to decide when to summon the team.
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.
An unclear verbal order leads to administration of the wrong drug.