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Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

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Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.

Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.

Handoffs and teamwork: a framework for care transition communication.

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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.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study.

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Falk A-C, Nymark C, Göransson KE, et al. Intensive Crit Care Nurs. 2022:103276.

Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

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Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

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.

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

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Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.

Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

Identifying Safety Events in the Prehospital Setting

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May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Check Twice, Transport Once

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May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.

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Frisch NK, Gibson PC, Stowman AM, et al. Am J Emerg Med. 2022;Epub Feb 21.

Electronic health records (EHR) can improve patient care and safety but are not without potential risks. A cyberattack led to a 25-day shutdown of a hospital’s EHR that necessitated a rapid shift to manual processes. This article outlines the laboratory service’s processes during the shutdown, including patient safety and error reduction, billing, and maintaining compliance with regulatory policies.

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

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Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.

I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.

Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.

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Blijleven V, Hoxha F, Jaspers MWM. J Med Internet Res. 2022;24:e33046.

Electronic health record (EHR) workarounds arise when users bypass safety features to increase efficiency. This scoping review aimed to validate, refine, and enrich the Sociotechnical EHR Workaround Analysis (SEWA) framework. Multidisciplinary teams (e.g. leadership, providers, EHR developers) can now use the refined SEWA framework to identify, analyze and resolve unsafe workarounds, leading to improved quality and efficiency of care.

A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.

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March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up.

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Domingo J, Galal G, Huang J. NEJM Catalyst. 2022;3.

Failure to follow up on abnormal diagnostic test results can cause delays in patients receiving appropriate care. This hospital used an artificial intelligence natural language processing system to identify radiology reports requiring follow-up. The system triggered automated notifications to the patient and ordering provider, and tracked follow-ups to completion. System development, deployment and next steps are detailed.

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

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Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.

Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

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Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;Epub Mar 7.

This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.

Systems engineering analysis of diagnostic referral closed-loop processes.

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Nehls N, Yap TS, Salant T, et al. BMJ Open Qual. 2021;10:e001603.

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic.

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Labrague LJ, Santos JAA, Fronda DC. J Nurs Manag. 2022;30:62-70.

Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.

Care transition of trauma patients: processes with articulation work before and after handoff.

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Wooldridge AR, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2022;98:103606.

Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.

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