Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
Young JQ, Ranji SR, Wachter RM, et al. Ann Intern Med. 2011;155:309-15.
The beginning of residency training for new interns has long been rumored to result in preventable harm for patients, a phenomenon known as the "July Effect" in the US and by the more macabre term "August killing season" in the UK. However, prior studies have reached conflicting conclusions about whether the "July Effect" truly exists. This systematic review of 39 studies provides the first comprehensive evidence that being hospitalized in July may actually be harmful, as a subset of larger and higher quality studies did find that mortality increased and efficiency of care decreased in association with new residents assuming their duties. Unfortunately, most studies included in the review had methodological flaws, meaning that the exact degree of harm could not be quantified.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory settings. Adoption of information technology approaches serves as a logical solution if designed to effectively notify providers of pending or necessary follow-up actions. This study used tracking software to determine if an electronic alert for abnormal imaging results was acknowledged and acted upon in a Veterans Affairs ambulatory setting. Investigators discovered that their seemingly fail-proof system, which included dual-alert communications, still led to persistent problems with missed test results. They also found that the dual-alert communication system was unexpectedly associated with a lack of timely follow-up. The authors advocate for greater multidisciplinary approaches to address these breakdowns.
Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-53.
The 2003 regulations that mandated 80-hour work week restrictions have generated significant debate over their impact on patient safety, fatigue, and discontinuity in care. This prospective study examined the role of intern workload and discovered that increased responsibilities were associated with greater sleep loss, longer shift durations, and less participation in educational activities. Investigators also determined that overnight duties during the week and early in the academic year were most problematic, a situation that is likely to worsen in the face of further work hour reductions being proposed. The authors advocate for greater research into workload, concerted efforts to minimize the administrative tasks of trainees, and thoughtful policies that balance patient safety and resident education.
Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33:19-29.
Efforts to comply with resident work-hour restrictions have placed a significant burden on hospitals and training programs, particularly in addressing the impact of these restrictions on patient safety. This AHRQ-supported study provides a framework to address the scheduling practices that aim to minimize sleep deprivation, optimize teamwork, and promote patient safety. The authors share a number of case examples and discuss policy implications around developing evidence-based scheduling and systematic culture change. This study’s lead author, Dr. Christopher Landrigan, was featured in a past AHRQ WebM&M conversation that discussed the role of sleep deprivation in residency training and its effect on medical errors.
Horwitz LI, Kosiborod M, Lin Z, et al. Ann Intern Med. 2007;147:97-103.
The 2003 regulations reducing housestaff duty hours have been controversial. Although some research has shown fewer errors when housestaff worked shorter shifts, many commentators have raised concern about the potential for errors associated with more transfers of care between physicians. This study sought to directly examine the effect of duty hours limitations on clinical outcomes by comparing medical patients hospitalized on a resident service to patients on a non-teaching service before and after duty hour reduction. There was no detectable increase in adverse events among patients cared for by residents, and some outcomes improved (eg, potential medication errors). Another study in the same issue also found reduced inpatient mortality among medical (but not surgical) patients after implementation of duty hour limitations. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours likely improved residents' quality of life, but the effect on patients has been controversial. A prior review did not find evidence linking reduced work hours to improved patient safety. This study analyzed administrative data from 591 community hospitals before and after implementation of duty hours limitations to determine their effect on inpatient mortality. Mortality was reduced among medical patients in teaching hospitals (compared with non-teaching hospitals) after duty hour limitations came into effect, but no such changes were seen in surgical patients. Another study published in the same issue found improvements in some clinical outcomes among medical patients at a single teaching hospital. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
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.
Van Eaton EG, Horvath KD, Lober WB, et al. J Am Coll Surg. 2005;200:538-45.
With growing pressure to develop methods for efficient communication, patient data collection, and resident sign-out, this study evaluated the implementation of an innovative web-based program. The computerized system securely organized important sign-out information, automatically downloaded daily patient data, and printed the data to designed templates. For the medical and surgical teams using the intervention, significantly more time was spent seeing patients rather than collecting data, improvements were reported in both sign-out and continuity of care, and nearly half the time was spent prerounding. The authors suggest that well-designed information technology systems can not only improve the quality of care but also address the importance of efficiency.
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