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Armstrong Institute for Patient Safety and Quality.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation.

Hospital discharge and readmission.

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Alper E, O'Malley TA, Greenwald J. UpToDate. June 15, 2022.

This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

Virtual Ambulatory CUSP Training.

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Armstrong Institute for Patient Safety and Quality. September 22-23, 2022.

The comprehensive unit-based safety program (CUSP) approach emphasizes active teamwork as a core element of improving safety culture through reporting and learning from errors. This virtual conference will cover how to engage teams in the ambulatory environment, address barriers to safe care, and learn from the experiences of others.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. June 14 and 16, 2022

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. April 20-June 22, 2022.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

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Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;Epub Jan 18.

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.

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

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Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

Curated Libraries

Maternal Safety

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

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May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

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Zimolzak AJ, Shahid U, Giardina TD, et al. J Gen Intern Med. 2022;37:137-144.

Inadequate follow-up of diagnostic testing can lead to missed or delayed diagnoses. Based on interviews with healthcare workers at Veterans Affairs (VA) facilities across the United States, this qualitative study identified factors contributing to lack of timely follow-up of abnormal test results. The most commonly cited factors included trainee/resident involvement, absence of a process to address incidental findings on imaging, lack of standardized electronic health records (EHR) and related tracking systems, and lack of updated patient and provider contact information. The authors summarize participant recommendations to reduce missed test results.

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

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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.

SAFER Care: improving caregiver comprehension of discharge instructions.

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Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147:e20200031.

Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of night float.

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Peterson C, Moore M, Sarwani N, et al. Diagnosis (Berl). 2021;8:368-372.

Recent duty hour reforms are intended to improve patient safety and resident well-being. This study explored whether resident performance declines as a function of consecutive overnight shifts, but results indicate no significant trend in overnight report discrepancies between the night float resident and the daytime attending.

Code Status vs. Care Status

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December 23, 2020

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

Delayed Breast Cancer Diagnosis: A False Sense of Security.

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December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other?

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Ashcroft J, Wilkinson A, Khan M. J Surg Educ. 2020;78:245-264.

This systematic review explored the different approaches taken by the United States and the United Kingdom to implement crew resource management (CRM) training. CRM in the United Kingdom had an emphasis on physicians and focused on skills outcomes using pre- and post-training questionnaires, whereas CRM in the United States focused on behavior outcomes and nontechnical skills utilizing multidisciplinary teams.

Intervention study for the reduction of medication errors in elderly trauma patients.

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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.

Patient Safety.

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Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.

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