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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.

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

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Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

The Leapfrog Hospital Survey.

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Leapfrog Group.

This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.

What is the medication iatrogenic risk in elderly outpatients for chronic pain?

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Jambon J, Choukroun C, Roux-Marson C, et al. Clin Neuropharmacol. 2022;45:65-71.

Polypharmacy in older adults is an ongoing safety concern due to the risk of being prescribed a potentially inappropriate medication or co-prescription of medications with dangerous interactions. In this study of adults aged 65 and older with chronic pain, 54% were taking at least one potentially inappropriate medication and 43% were at moderate or high risk of adverse drug events. Measures such as involvement of a pharmacist in medication review could reduce risk of adverse drug events in older adult outpatients.

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.

Clinical progress note: situation awareness for clinical deterioration in hospitalized children.

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Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework.

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Acorda DE, Bracken J, Abela K, et al. Jt Comm J Qual Patient Saf. 2022;48:196-204.

Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements.

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

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April 27, 2022

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;Epub Apr 4.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients. Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

Family support role in hospital rapid response teams: a scoping review.

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Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;Epub Mar 4.

Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

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.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

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April 7, 2022

Mobile health apps are becoming increasingly popular for patients and clinicians. This innovative study implemented a pharmacist-led mobile health based intervention to improve medication safety of patients following kidney transplant.

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

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Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.

Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.

Annual Perspective: Topics in Medication Safety

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March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020.

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Kukielka E, Jones R. Patient Safety. 2022;4:49-59.

Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.

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.

Antibiotic prescribing errors in patients discharged from the pediatric emergency department.

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LaScala EC, Monroe AK, Hall GA, et al. Pediatr Emerg Care. 2022;38:e387-e392.

Several factors contribute to pediatric antibiotic medication errors in the emergency department, such as the frequent use of verbal orders and the need for weight-based dosing. Results of this study align with previous research and reinforce the need for further investigation and interventions to reduce antibiotic medication errors such as computerized provider order entry.

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.

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Huang C, Barwise A, Soleimani J, et al. J Patient Saf. 2022;18:e454-e462.

Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic error played a part in rapid response team activations or unplanned admissions to the intensive care unit. Clinicians reported that 18% of acute care patients experienced diagnostic errors.

Implementation of an antibiotic stewardship program in long-term care facilities across the US.

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Katz MJ, Tamma PD, Cosgrove SE, et al. JAMA Netw Open. 2022;5(2):e220181.

Overuse of antibiotics has been common in nursing homes; therefore, antibiotic stewardship programs (ASPs) have been emphasized by experts. To assist facilities, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use developed programs and a toolkit to improve the appropriate use of antibiotics. This quality improvement program found that a focused educational initiative to establish ASPs in nursing homes was associated with reduction in antibiotic use in those facilities with high levels of engagement.

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