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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.
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.
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.
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.
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. 
Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.
Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 

AHA Team Training.
 

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 

Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.
Ihlebæk HM. Int J Nurs Stud. 2020;109:103636.
Using ethnographic methods, this study explored the impact of ‘silent report’ (computer-mediated handover) on nurses’ cognitive work and communication. The authors summarize four emerging themes, which highlight and characterize the importance of oral communication to ensure accurate and useful handovers.
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.