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Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
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.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
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.  
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
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.  
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. J Patient Saf. 2013;9.
Conceptually analogous to failure mode and effect analysis, the Bow-Tie method is used to prospectively detect safety hazards. In this study, the Bow-Tie method was used to identify latent safety hazards in intrahospital transport, risk factors for unintentional extubation, and contributors to poor interdisciplinary communication.
Schneider EB, Hirani SA, Hambridge HL, et al. J Surg Res. 2012;177:295-300.
Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.
van Walraven C, Jennings A, Taljaard M, et al. Can Med Assoc J. 2011;183.
Readmissions after hospital discharge are common and may be related to adverse events after discharge. However, this Canadian study of discharges from 11 hospitals found that fewer than 1 in 5 urgent readmissions could be considered preventable. Both this proportion and the overall incidence of readmissions varied widely across individual hospitals.
Bapoje SR, Gaudiani JL, Narayanan V, et al. J Hosp Med. 2011;6:68-72.
Patients should improve, not worsen, after hospital admission, and therefore safety interventions such as rapid response teams (RRTs) have been developed specifically to detect and manage unexpected clinical deterioration. This retrospective review of 152 unplanned transfers to the intensive care unit (ICU) at a teaching hospital found that only 15% of unplanned transfers could have been prevented by different management after admission. The most common reason for unplanned ICU transfer was incorrect triage (i.e., the patient should have been admitted directly to the ICU from the emergency department). This study challenges the utility of RRTs in preventing adverse clinical outcomes, and instead identifies the emergency department–inpatient handover as a possible area of focus for quality improvement interventions.
Hess DR, Tokarczyk A, O'Malley M, et al. Chest. 2010;138:1475-9.
Teamwork and communication failures are a continued threat to patient safety. Intensive care units (ICU) have demonstrated the impact of different strategies to address these failures and improve patient outcomes. This study, targeting patients with prolonged respiratory failure, involved adding a verbal telephone report to an existing written one during transfer from the ICU. While the strengthened handoff process was associated with a trend toward reduced readmissions, its most impressive impact was on the total cost of care per patient, which fell significantly. Investigators estimated that nearly $185,000 was saved per 100 discharges, arguing that their intervention represents an improvement in the value of care (quality divided by cost) for this population. An accompanying editorial [see link below] discusses the implications of these findings and the broader role of poor communication in medical errors.
Jukkala AM, Kirby RS. MCN Am J Matern Child Nurs. 2009;34:365-371.
This survey of rural hospitals in the southern United States found that hospitals with fewer than 125 deliveries per year were relatively less prepared to administer neonatal resuscitation. As well, one-third of hospitals did not have an established method for transferring patients to tertiary care hospitals.
Gandara E, Moniz TT, Ungar J, et al. Jt Comm J Qual Patient Saf. 2008;34:460-3.
Many patients discharged from hospitals on anticoagulant medications (including warfarin and heparin) lacked adequate documentation of the duration of therapy and monitoring needs. Ensuring the safety of anticoagulant therapy is a Joint Commission National Patient Safety Goal.
Chaboyer W, Thalib L, Foster M, et al. Am J Crit Care. 2008;17:255-63; quiz 264.
This study analyzed the most common adverse events following discharge from an intensive care unit and discovered that a respiratory rate of less than 10 breaths/minute or greater than 25 breaths/minute and a heart rate of more than 110 beats/minute were significant independent predictors. Nursing care requirements also predicted adverse events in limited analyses, which the authors suggest is an area for future investigation.
Sklar DP, Crandall CS, Loeliger E, et al. Ann Emerg Med. 2007;49.
This retrospective cohort study, conducted over a 10-year period, linked hospital records and state death records to identify patients who died within 7 days of being discharged from the emergency department (ED). Approximately 30 unexpected deaths occurred per 100,000 ED discharges, and a potential error or misdiagnosis was detected in more than half of these cases. Although prior research found that both physician knowledge and system factors contributed to missed diagnoses in the ED, in this study, unexpected post-discharge deaths were more commonly associated with unusual illnesses or psychiatric or substance abuse comorbidities.