Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319:1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Handoffs represent a significant risk to patient safety. Standardizing communication during the handoff process has the potential to reduce harm. In this trial, researchers assessed the impact of a standardized handoff curriculum on perceived interprovider communication in eight intensive care units (ICUs) across two hospital systems. Although the curriculum was perceived to improve shift preparedness among providers, they found no association with better patient outcomes in the ICUs, including length of stay, duration of mechanical ventilation, or reintubations. An accompanying editorial suggests that further research on standardized handoffs in the ICU is necessary to better understand the potential for improving patient outcomes. A previous PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319:143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
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.
Murphy DR, Wu L, Thomas EJ, et al. J Clin Oncol. 2015;33:3560-7.
Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.
Starmer AJ, Spector ND, Srivastava R, et al. New Engl J Med. 2014;371:1803-1812.
The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.
Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Handoff improvement is a national patient safety priority. The Accreditation Council for Graduate Medical Education now requires residency programs to provide formal handoff education to trainees. This study evaluated the implementation of an inpatient handoff bundle for pediatric resident physicians. The multifaceted intervention included team training, standardized communication, electronic documentation, and new team handoff structures. In the uncontrolled, before-and-after analyses, medical errors and preventable adverse events decreased substantially. The intervention did not adversely affect resident workflow. Residents were found to spend more time in direct contact with patients in the post-intervention period. A related editorial notes that this study presents promising evidence that improving handoffs can reduce patient harm.
Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.
Preventing readmissions after hospital discharge is a national policy priority. The Partnership for Patients has established a goal of reducing preventable readmissions by 20% by 2013, and hospitals now face financial penalties for excess readmission rates. However, the proportion of readmissions that is truly preventable remains unclear, as prior studies have found that only 1 in 5 readmissions may be preventable. This case series from the integrated Kaiser Permanente system found that nearly half of their 30-day readmissions were at least possibly preventable (with 11% being completely preventable). Most readmissions had multiple contributing causes, and interestingly, use of strategies to prevent readmissions such as postdischarge telephone calls and early primary care follow-up appointments varied widely across the 18 hospitals in the study. A potentially preventable readmission due to a medication error is discussed in an AHRQ WebM&M commentary.
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.
The Partnership for Patients has set a goal of reducing preventable hospital readmissions 20% by the year 2013. This goal was achieved by the landmark care transitions study. However, since that study was conducted in an integrated health care system, concerns linger about the generalizability of the intervention to other settings. This study, funded by the Centers for Medicare and Medicaid Services, sought to evaluate the real world effectiveness of the care transitions intervention at six hospitals in a non-integrated health care system. Despite logistical challenges, the intervention successfully reduced readmissions by 36% in patients who received it compared with patients who did not receive any component of the intervention. As hospitals continue to investigate ways of preventing readmissions and reducing adverse events after discharge, this study provides reinforcement for comprehensive interventions that attempt to bridge the gap between inpatient and outpatient care.
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.
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.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
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.
Jha AK, Chan DC, Ridgway AB, et al. Health Aff (Millwood). 2009;28:1475-1484.
The seminal Institute of Medicine report To Err Is Human estimated that preventable errors cost the US health care system more than $17 billion annually. Although hospitals themselves currently bear only a small proportion of these costs, payers are increasingly seeking to realign incentives to both improve safety and control costs. This study examined the costs associated with both preventable adverse events and redundant tests (duplicate tests ordered for the same patient by different physicians). The authors estimate that eliminating preventable adverse events (principally health care–associated infections) alone could save the US health system more than $16 billion annually, with an additional $8 billion in savings potentially achievable by eliminating redundant tests. The Centers for Medicare and Medicaid Services' policy eliminating reimbursement for certain preventable conditions is an attempt to address this issue. A companion article explains that the savings realized by this policy are likely to be minimal.
Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-6.
Adverse events after hospital discharge are a continued threat to patient safety and a significant source of communication failures, particularly for tests that are pending at discharge. This study reviewed nearly 700 discharge summaries from two academic centers and found that only 16% of pending tests were mentioned and that only 13% of discharge summaries listed all pending tests. Equally concerning was that follow-up providers' information was documented in only 67% of cases. Recognition of these problems has led to the development of discharge checklists and reengineering of the process. A past AHRQ WebM&M perspective and interview discussed issues around safe care transitions.
Attempts to reduce medication discrepancies in hospitalized patients have been hampered by a lack of proven medication reconciliation strategies. In this cluster-randomized trial, a previously described electronic medication list that required input from nurses, physicians, and pharmacists was implemented at two academic hospitals. The tool resulted in a significant reduction in potential adverse drug events at discharge. However, potential drug errors still occurred at a rate of one per patient even after implementation. The intervention was more successful at preventing medication discrepancies among high-risk patients. This study is one of the first randomized trials of a medication reconciliation intervention, and points the way toward identifying medication reconciliation tools that are widely applicable.
van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-8.
Significant attention to gaps in the continuity of care has led to past research focused on hospital transitions and medication management systems in the ambulatory setting. This study tracked information exchange between outpatient providers caring for the same patient following hospital discharge. Remarkably, they discovered that information from the previous visit was available at a subsequent visit only 22% of the time. Factors associated with information being available included care by a family physician and whether that physician was treating the patient prior to hospitalization. The findings raise ongoing concerns about poor communication and highlight the need for systems to foster more effective clinical information exchange between providers. A past AHRQ WebM&M perspective discussed care transitions associated with hospital discharge.
Roy CL, Kachalia A, Woolf S, et al. J Gen Intern Med. 2009;24:374-80.
Hospital readmissions are garnering increased attention as a potential measure of care transition quality. When readmissions occur, providing feedback to the team that originally discharged the patient could be valuable. This study, conducted at two academic medical centers, found that discharging physicians frequently were not informed that their patient had been readmitted. Communication between discharging and readmitting teams took place in a minority of cases, even though most clinicians felt that communication would have been useful. A recent AHRQ WebM&M perspective discussed hospital readmissions as well as methods to reduce them, including use of a transitions coach.
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