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Search results for "Hospitals"

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Journal Article > Commentary

Patient safety: let's measure what matters.

Thomas EJ, Classen DC. Ann Intern Med. 2014;160:642-643.

This commentary discusses challenges related to the use of numerous measures for adverse events in hospitals in the United States. The authors explain how continually adding mandated safety measures can detract from safety improvement by overwhelming hospital workers with the burden of tracking and failing to record new types of errors.

Journal Article > Study

Who do hospital physicians and nurses go to for advice about medications? A social network analysis and examination of prescribing error rates.

Creswick N, Westbrook JI. J Patient Saf. 2015;11:152-159.

This analysis sought to characterize how physicians and nurses acquire information about medication prescribing. Physicians rarely elicited medication prescribing advice from individuals and more frequently referred to paper or computerized resources. A ward with a better information-sharing network had fewer medication errors, highlighting the value of interprofessional information-sharing as a critical component of safety culture.

Journal Article > Study

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.

This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.

Book/Report

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.

Journal Article > Study

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands.

Eindhoven DC, Borleffs CJW, Dietz MF, Schalij MJ, Brouwers C, de Bruijne MC. BMJ Open. 2017;7:e014360.

Although adverse events among hospitalized patients are common, less is known about the safety of acute cardiac care. In this retrospective study, researchers described the development and validation of a tool to assess the safety of patients treated for acute myocardial infarction.

Journal Article > Study

'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective.

Ferguson J, Keyworth C, Tully MP. Res Social Adm Pharm. 2017 Mar 2; [Epub ahead of print].

This qualitative study of physician trainees found that they welcomed feedback about prescribing errors. Feedback was perceived to be most useful if it was timely, specific, and included group discussion. Participants found email feedback to be less useful. These data should inform future efforts to provide prescribing feedback.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Journal Article > Study

Pediatric prehospital medication dosing errors: a national survey of paramedics.

Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Prehosp Emerg Care. 2017;21:185-191.

This survey of paramedics found that pediatric dosing errors in the prehospital period are common. Respondents used varied methods for estimating weight of pediatric patients in order to calculate drug doses, and they advocated for pediatric training and standardized weight estimation methods to reduce risks. These findings suggest several possible interventions to enhance pediatric medication safety in the prehospital setting.

Journal Article > Study

Performance of a trigger tool for identifying adverse events in oncology.

Lipitz-Snyderman A, Classen D, Pfister D, et al. J Oncol Pract. 2017;13:e223-e230.

Investigators developed and validated a trigger tool to identify a range of harms in cancer care. Although their final tool had only a modestly accurate positive predictive value, they advocate refining and automating the trigger approach to enhance the detection of adverse events in oncology.

Journal Article > Study

Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.

  • Classic

Lin LA, Bohnert AS, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Pain. 2017;158:833-839.

Opioids are known to be high-risk medications, and unsafe prescribing practices are common. This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback to clinicians about high-risk opioid prescribing. Local champions implemented the dashboard tool and spearheaded safer opioid prescribing. Using an interrupted time series analysis, researchers determined that the intervention reduced two unsafe prescribing practices: high-dose opioid prescriptions and concurrent use of opioids and benzodiazepines. The authors suggest that this type of large-scale intervention could be applied in other health care systems to enhance opioid safety. A recent Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to foster safer opioid use.

Journal Article > Commentary

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

Siedlecki SL, Albert NM. Clin Nurse Spec. 2017;31:23-29.

The ability to proactively identify and mitigate risk is key to safety improvement. This commentary describes several risk assessment tools available to develop estimates of potential adverse events and discusses how to ensure those assessments are valid and reliable.

Journal Article > Study

Adverse event and error of unexpected life-threatening events within 24h of emergency department admission.

Zhang E, Hung SC, Wu CH, Chen LL, Tsai MT, Lee WH. Am J Emerg Med. 2017;35:479-483.

Trigger tools are frequently utilized to identify adverse events. The authors of this prospective study suggest that unexpected life-threatening events that occur within 24 hours of admission from the emergency department may be a useful trigger tool.

Journal Article > Study

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

Journal Article > Study

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.

Mort E, Bruckel J, Donelan K, et al; Peer-to-Peer Study Team. Am J Med Qual. 2016 Oct 23; [Epub ahead of print].

Patient safety approaches often draw from high reliability industries outside of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear power industry. Two academic medical centers assessed each other's patient safety performance. Each center examined its peer's prevention of central line–associated bloodstream infections (CLABSI), hand hygiene compliance, and overall safety culture as an organization. Peer-to-peer assessments were conducted via site visits, which involved interviews and direct observation. They resulted in rapid practice changes such as dissemination of unit-specific CLABSI rates and central line procedure audits. The process was widely accepted by leaders and frontline staff at both sites. The authors contend that peer-to-peer assessment is feasible and has potential to improve patient safety.

Journal Article > Commentary

Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.

Larson DB, Donnelly LF, Podberesky DJ, Merrow AC, Sharpe RE Jr, Kruskal JB. Radiology. 2017;283:231-241.

Improving the culture of safety within health care is an essential component of preventing errors. This commentary discusses the culture of radiology in the context of recent progress in understanding and reducing diagnostic error. The authors suggest that peer-oriented feedback and assessment would drive progress in improving safety in radiology.

Journal Article > Commentary

Using a change model to reduce the risk of surgical site infection.

Burden M. Br J Nurs. 2016;25:949-955.

Surgical site infections can result in harm and financial hardship for patients. In light of increased rates of surgical site infections among patients with breast cancer, this commentary describes how a project applied a classic change model to enhance existing processes to address behavioral and cultural barriers to improvement and reduced surgical site infections over the course of the initiative. Team collaboration was highlighted as a key element of the project's success.

Journal Article > Study

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.

Segall N, Bonifacio AS, Barbeito A, et al. Jt Comm J Qual Patient Saf. 2016;42:400-414.

Human factors engineering aims to optimize performance by examining the relationship between individuals and the system within which they work. This field of study has long been used to improve the safety of industries like manufacturing and aviation, and it has more recently been applied to health care. This study used human factors approaches to conduct observations, surveys, interviews, and focus groups about handoffs, specifically for postsurgical patients transferred from the operating room to the intensive care unit. The investigators identified flaws in handoff practices; then they designed a standardized handoff process to address these vulnerabilities. The redesigned handoff did not take more time than prior handoffs but did demonstrate better participant satisfaction. The authors suggest that their human factors-based improvement approach could be applied to other patient safety processes. A past PSNet interview discussed the application of human factors to health care.

Journal Article > Study

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.

  • Classic

Nguyen OK, Makam AN, Clark C, et al. J Gen Intern Med. 2017;32:42-48.

Identifying patients at high risk of readmission following hospital discharge is a patient safety priority. This observational cohort study found that patients with abnormal vital signs—temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation—upon hospital discharge were more likely to be readmitted to the hospital or die within 30 days compared to patients without vital sign abnormalities. The authors suggest vital signs should be used to assess safety for hospital discharge.

Journal Article > Study

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

Zachariasse JM, Kuiper JW, de Hoog M, Moll HA, van Veen M. J Pediatr. 2016;177:232-237.

Emergency department triage systems are designed to prioritize patients based on the level of illness. Inappropriate triage can lead to delays in care and adverse events. In Europe, the Manchester Triage System is a widely used algorithm that classifies patients based on five levels of urgency with a corresponding maximum waiting time. This study sought to assess the effectiveness of the Manchester Triage System in children requiring admission to the intensive care unit (ICU). Analyzing more than 50,000 consecutive emergency department visits of children younger than 16, the authors determined that almost one third of children admitted to the ICU were undertriaged. Risk factors identified for undertriage included age younger than 3 months, type of medical presenting problem, presence of underlying chronic conditions, referral by a specialist or emergency medical services, and arrival during the evening or at night. These findings suggest that the Manchester Triage System inappropriately triages a significant proportion of children requiring ICU admission and that modifications should be made to improve safety in pediatric emergency care. A previous WebM&M commentary discussed the challenges of triage in the emergency department.

Journal Article > Study

Potentially preventable 30-day hospital readmissions at a children's hospital.

Toomey SL, Peltz A, Loren S, et al. Pediatrics. 2016;138:e20154182.

Readmissions to the hospital are considered a marker of patient safety, and hospitals with high readmission rates are subject to reduced Medicare reimbursements. The extent to which readmissions are preventable remains controversial. Investigators examined 300 pediatric readmissions at a single hospital with input from inpatient providers, primary care providers, patients, family members, and medical records. They determined that approximately 30% of readmissions were preventable. Both patient-related factors such as parental anxiety and hospital-related factors such as hospital-acquired conditions contributed to preventable readmissions. The authors emphasize the importance of interviewing patients and family members as well as medical providers to better characterize the preventability of readmissions. They suggest that identifying factors associated with preventable readmissions will lead to readmission reduction strategies. Multiple strategies targeting the different contributing factors will likely be needed. A past PSNet interview reflected on the challenge of preventing readmissions.

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