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.
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.
Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Goldberg SA, Porat A, Strother CG, et al. Prehosp Emerg Care. 2017;21:14-17.
Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) are known to be suboptimal. This record review of 90 EMS-to-ED handoffs at a single academic medical center found that essential information was often omitted. The authors suggest that further training is needed to enhance the quality of these handoffs.
O'Hara R, Johnson M, Siriwardena N, et al. J Health Serv Res Policy. 2015;20:45-53.
This qualitative study explored decision-making by prehospital emergency providers and the effect these decisions can have on patient safety. The study identified both system-level and individual factors that influence critical decisions.
Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Policy. 2015;20:17-25.
Patient handoffs are a major challenge for patient safety, especially when patients move between different units or organizations. Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality of handoffs.
Wood K, Crouch R, Rowland E, et al. Emerg Med J. 2015;32:577-581.
This review calls for research to understand challenges related to time, resources, and interprofessional relationships that affect information transfer between prehospital and hospital staff before implementing standard methods and tools for this type of handoff.
Meisel ZF, Shea JA, Peacock NJ, et al. Ann Emerg Med. 2015;65:310-317.e1.
This focus group study with emergency medical services personnel identified several potential ways to improve the quality of handoffs between paramedics and emergency department staff. A structured handoff tool has been developed to address this known safety hazard.
Balka E, Tolar M, Coates S, et al. Int J Med Inform. 2013;82:e345-57.
This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-33.
Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.
Bigham BL, Buick JE, Brooks SC, et al. Prehosp Emerg Care. 2012;16:20-35.
This systematic review found that the literature base on patient safety issues in prehospital care is still quite small, limiting emergency medical services providers' ability to identify and address systematic problems in care.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.
Greenwood MJ, Heninger JR. Prehosp Emerg Care. 2010;14:345-8.
This article describes a case where lack of clarity in communication contributed to the death of a patient and highlights strategies to prevent similar failures, including read back and critical assertion.
Lim MTC, Ratnavel N. Pediatr Crit Care Med. 2008;9:289-93.
This study discovered that avoidable human errors contribute to the majority of adverse events around interhospital transfers, and targeted prevention strategies should include further education and training efforts.
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