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1 - 20 of 28

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.
Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 
Britton MC, Hodshon B, Chaudhry SI. J Patient Saf. 2019;15:198-204.
This implementation study describes a new workflow of a telephone call between discharging clinician at an acute care hospital and treating physician at a skilled nursing facility to improve handoffs. Researchers report increasing implementation of this "warm handoff," tempered by concerns about clinician workload and efficiency. The authors conclude that while warm handoffs show promise, the organizational and workflow context could better support this safety strategy.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Lane SJ, Troyer JL, Dienemann JA, et al. Health Care Manag Rev. 2014;39:340-351.
According to this study, dose omissions were the most common medication errors occurring during transitions to nursing home care. However, the wide range of errors detected suggests that multifaceted interventions would be needed to improve medication safety. A prior AHRQ WebM&M interview and its accompanying perspective discuss safety in nursing homes.
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.
This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.
Tjia J, Bonner A, Briesacher BA, et al. J Gen Intern Med. 2009;24:630-5.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Boling PA. Clin Geriatr Med. 2009;25:135-48, viii.
This article reviews the literature on transitions of care, discusses interventions, and suggests that transitional care processes supported by effective home care programs can reduce rehospitalization.
Boockvar KS, Liu S, Goldstein N, et al. Qual Saf Health Care. 2009;18:32-6.
Posthospital medication discrepancies are a known safety issue, with the resulting errors stemming from unintended events as well as from the broader transitions in care. Medication reconciliation was named as a 2005 National Patient Safety Goal in part to address these concerns at various transition points in a patient's hospitalization. This study analyzed more than 200 patients' medication records during transitions between acute hospital and their nursing homes to determine the predictive value of medication discrepancies for adverse drug events (ADEs). Investigators found that the drug classes at highest risk for discrepancy-related ADEs were opioid and nonopioid analgesics, providing a specific target for future intervention. A past AHRQ WebM&M commentary discussed the importance of medication reconciliation and barriers to successful adoption, and suggested best practices.