Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56(5):885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132(6):1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
Abraham J, Meng A, Tripathy S, et al. BMJ Qual Saf. 2021;30(6):513-524.
Handoffs are essential to communicating important information and preventing adverse outcomes. This systematic review found that bundled interventions commonly used to support handoffs between the operating room and intensive care units included information transfer/communication checklists and protocols. A meta-analysis showed that bundled interventions resulted in significant improvements for a number of clinical and process outcomes, such as time to analgesia dosing, fewer information omissions, and fewer technical errors.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.
Boet S, Djokhdem H, Leir SA, et al. Br J Anaesth. 2020;125(4):605-613.
Handoffs between providers can introduce patient safety risks. This systematic review explored the impacts of intraoperative anesthesia handovers (e.g., intraoperative relief, transferring care to an incoming provider) on patient safety outcomes. The researchers pooled four studies and found that an intraoperative anesthesia handover significantly increases the risk of an adverse event by 40%.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35(10):1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes. This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Ashcroft J, Wilkinson A, Khan M. J Surg Educ. 2020;78(1):245-264.
This systematic review explored the different approaches taken by the United States and the United Kingdom to implement crew resource management (CRM) training. CRM in the United Kingdom had an emphasis on physicians and focused on skills outcomes using pre- and post-training questionnaires, whereas CRM in the United States focused on behavior outcomes and nontechnical skills utilizing multidisciplinary teams.
Alqenae FA, Steinke DT, Keers RN. Drug Saf. 2020;43(6):517-537.
This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.
Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882.
Physicians commonly use diagnostic algorithms and practice guidelines to individualize risk assessment and guide clinical decisions. The authors discuss the possible dangers of using race-adjusted algorithms due to their potential to lead to diagnostic errors and delays in care.
Ogletree AM, Mangrum R, Harris Y, et al. J Am Med Dir Assoc. 2020;21(5):604-614.e6.
To support the development of a uniform definition of omissions of care in nursing home settings, the authors conducted a thematic analysis of 34 articles describing existing definitions and found broad agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include adverse events in the definition of omissions of care. The authors reviewed an additional 327 articles reporting adverse events attributable to omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls, and infections.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46(6):314-320.
As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.
Herledan C, Baudouin A, Larbre V, et al. Support Care Cancer. 2020;28(8):3557-3569.
This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.
Prior research has found poor communication between hospital-based and primary care physicians and has suggested that this may contribute to medical errors. This systematic review included 19 studies assessing the transfer of information at hospital discharge between hospital-based and primary care providers (PCPs), or evaluating interventions aimed at improving the timeliness and quality of discharge information. The review found that timely communication of discharge summaries was low, with 55% (median) transferred to PCPs within 48 hours and 85% (median) within 4-weeks; 8.5% of discharge summaries were never transferred. Discharge summaries nearly always contained patient demographics, admission/discharge dates and primary diagnoses, but less frequently included pending test results, diagnostic tests performed and discharge medications.
Anderson JE, Ross AJ, Back J, et al. Int J Qual Health Care. 2020.
Using ethnographic methods and resilient healthcare principles (described as systems that anticipate future demands, respond to current demands, monitor for emergent problems and learn from results, both positive and negative), the researchers interviewed and observed staff in emergency departments (EDs) and geriatric wards in one teaching hospital in London to identify system vulnerabilities to target with quality improvement interventions. The observations and interviews revealed difficulties with discharge planning and information integration as priority areas.
Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.
Project RED re-engineered discharge with the goal of reducing preventable readmissions. This report summarizes an Agency for Healthcare Research and Quality project to transfer the Project RED experience to the primary care environment. Areas of focus included enhancing the team leader role of primary care physicians in post-discharge care.
Song Y, Hoben M, Norton PG, et al. JAMA Netw Open. 2020;3.
The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.
A Decade of Patient Safety 2020-2030. Geneva, Switzerland; World Health Organization: February 2020.
The World Health Organization (WHO) is a primary motivator for global patient safety improvement. This initiative announcement outlines the overarching WHO approach to implementing an international resolution to integrate institutional programs across health care to enhance care delivery and reliability.
Trauma patients are particularly vulnerable to medication errors due to the severity of their injuries and the multiple handoffs and transitions often occurring during their hospital stay. This article reviewed existing medication reconciliation strategies and found that many have poor accuracy, can be costly and time-consuming, and may not be applicable to a trauma population. The authors comment on the urgent need for research supporting safe and efficient medication reconciliation in trauma patients.
McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46(4):341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
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