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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.

Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;Epub Apr 22.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.
Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.
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.
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.
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.
Willis E, Brady C. Nurs Open. 2022;9:862-871.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.1 Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.2 Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.2

Building on prior studies, a team at the Cleveland Clinic Health System (CCHS) implemented a home visit program, called High Risk Transitions in Care (HRTIC), with the goal of reducing 30-day hospital readmissions for discharged patients at high risk for readmission.2 The program aimed to leverage the scope of practice of advanced practice registered nurses (APRNs) along with acute care skills offered by paramedics.

The innovation evolved in two phases. In the first phase, the CCHS team experimented with a model that offered three home visits provided by either APRNs or paramedics in the first four weeks following discharge. After five months in Phase 1, the CCHS team found no significant difference in readmission rates for the participating population when compared with a matched cohort.2 In Phase 2, CCHS adapted the innovation by delivering a total of four home visits to referred patients within 30 days of discharge. APRNs provided the first post-discharge home visit, and paramedics, in coordination with the APRN and the patient’s larger care team, often provided subsequent home visits.2 After six months, the home visit program was associated with about 10% fewer readmissions when compared with a matched cohort.2

Beyond the additional home visit, the CCHS team believes that a key reason that the Phase 2 results were encouraging was that the patients received care from both types of providers, receiving both the APRNs’ skill as independent practitioners to diagnose and treat illnesses and the paramedics’ rapid response capabilities and acute care experience.

To evaluate the longer-term effects of the HRTIC program, the CCHS team compared readmission rates 60 and 90 days after hospital discharge for the Phase 2 group with those of a matched comparison group. Readmission rates did not differ between the two groups, indicating a potential need to extend visits beyond four weeks to sustain outcomes.2

Factors that contribute to sustaining a successful program, according to the CCHS team, include a centralized referral system that utilizes an administrative team to schedule the home visits. The team said the innovation requires flexible criteria for identifying high-risk patients in case the criteria need to be adjusted because the program does not have the capacity to serve the existing volume of referred patients. In the future, the CCHS team would like to explore the reasons patients decline home visit programs and strategies for increasing patient participation.

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).1 Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital. The University of Michigan Emergency Critical Care Center (EC3) opened on February 16, 2015, as a 7,800-square-foot unit with five resuscitation or trauma bays and nine critical care patient rooms immediately adjacent to the main ED.4 The goal of EC3 is to deliver early, aggressive, evidence-based critical care to the most acutely ill and injured patients arriving to the ED.

Prior to opening EC3, all ED patients requiring ongoing critical care were evaluated and treated by the ED team in resuscitation bays or regular ED rooms until an inpatient ICU bed became available or the patient no longer required critical care and was admitted to a non-ICU level of care.

Studies of the EC3 initiative have found promising outcomes, including modest but significant decreases in mortality (14.1% reduction in adjusted 30-day mortality for ED patients in the post-EC3 cohort; number needed to treat [NNT]=220 patients to reduce 1 death at 30 days),5 reduced ICU utilization (12.9% reduction in the post-EC3 cohort; NNT=179 patients to reduce 1 ICU admission), quicker patient turnover, and shorter hospital stays.5,6

The EC3 care team is comprised of emergency medicine (EM) physicians (with or without critical care fellowship training), house staff (primarily EM residents and critical care fellows), physician assistants (with critical care training), ED nurses (with additional ICU training), respiratory therapists, and pharmacists. The patient-to-nurse ratio is the same as most traditional inpatient ICUs at 2:1.7 EC3 has treated over 16,000 patients to date.

For this type of innovation to ultimately be successful, EC3 leadership recommend that care be evidenced-based and protocol-driven, yet the care team remain flexible and nimble enough to adapt to the constantly changing conditions inherent within the world of emergency medicine. Further, EC3 leadership emphasize that all care providers need to remain well-versed in the knowledge and skillsets needed to provide both EM-centric resuscitation and stabilization as well as the early and continuing critical care knowledge and skillsets more traditionally found in inpatient ICUs. Obtaining these knowledge and skills requires the innovating organization to provide continual training and evaluation and feedback to the care team. Additionally, since the initiative requires significant resources, it is important to keep thorough data pre- and post-implementation to demonstrate impact on patient-centric outcomes.

Lane S, Gross M, Arzola C, et al. Can J Anaesth. Epub 2022 Mar 22.

Intraoperative anesthesia handovers can increase patient safety risks. Based on video-recorded handovers and anesthetic records, researchers at this tertiary care center found that introduction of an intraoperative handover checklist improved handover completeness, which may decrease risk for adverse events.

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.

March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.

Transitions of care from inpatient to outpatient settings are vulnerable to medication errors. This study found that patients receiving pharmacist-led medication reconciliation and education prior to discharge reported higher patient satisfaction scores; lower readmission rates compared to standard care patients were also observed. Pharmacists potentially prevented 143 medication safety events during medication reconciliation.
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.
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.

Armstrong Institute for Patient Safety and Quality. May 12-13, 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.
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.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
AHA Training. May 16-17, 2022, Founders Room, University of California Los Angeles, Los Angeles, CA.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.
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.