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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.

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.

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.

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

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Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;Epub Apr 19.

Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.

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.

On Patient Safety.

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Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. June 14 and 16, 2022

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

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.

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.

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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.

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

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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.

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.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

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April 7, 2022

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.

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

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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.

Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions.

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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.

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.

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

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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%.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. April 20-June 22, 2022.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

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