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Search results for "United States of America"

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Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

Newspaper/Magazine Article

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

Journal Article > Commentary

An innovative collaborative model of care for undiagnosed complex medical conditions.

Nageswaran S, Donoghue N, Mitchell A, Givner LB. Pediatrics. 2017;139:e20163373.

Lack of collaboration among the clinical team can contribute to diagnostic problems. This commentary describes a collaborative model of care developed to enhance interdisciplinary teamwork across health care settings as a strategy to augment diagnosis for children with undiagnosed complex medical conditions.

Journal Article > Study

Quality of handoffs in community pharmacies.

Abebe E, Stone JA, Lester CA, Chui MA. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

Journal Article > Commentary

Beyond medication reconciliation: the correct medication list.

Rose AJ, Fischer SH, Paasche-Orlow MK. JAMA. 2017;317:2057-2058.

Although medication reconciliation is widely advocated to improve medication safety, barriers to implementation persist. This commentary describes strategies to improve the process to ensure patients and care teams have accurate medication lists. Recommendations include involving the patient in reconciliation and clarifying which provider is responsible for the task.

Journal Article > Commentary

A quality improvement approach to standardization and sustainability of the hand-off process.

Fryman C, Hamo C, Raghavan S, Goolsarran N. BMJ Qual Improv Rep. 2017;6:u222156.w8291.

Electronic handoff tools can facilitate information sharing between teams. This quality improvement report reviews the results of an initiative that used plan-do-study-act cycles to assess the integration of the I-PASS handoff process into an electronic medical record system.

Journal Article > Study

Measuring to improve medication reconciliation in a large subspecialty outpatient practice.

Kern E, Dingae MB, Langmack EL, Juarez C, Cott G, Meadows SK. Jt Comm J Qual Patient Saf. 2017;43:212-223.

Achieving accurate medication reconciliation during care transitions helps promote patient safety. Using data from the electronic health record, researchers developed and validated metrics to assess performance of medication reconciliation in the ambulatory setting.

Newspaper/Magazine Article

High-reliability and the I-PASS communication tool.

Clements K. Nurs Manage. 2017;48:12-13.

High reliability has yet to be achieved in health care organizations. This magazine article described how a 13-hospital health system used handoff standardization tools such as I-PASS to enhance the reliability of patient transitions.

Journal Article > Study

Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic.

Rattray NA, Sico JJ, Cox LM, Russ AL, Matthias MS, Frankel RM. Jt Comm J Qual Patient Saf. 2017;43:127-137.

Communication between inpatient clinicians and primary care physicians at the time of hospital discharge is often suboptimal, and it may not have improved with the advent of electronic health records. This qualitative study examined barriers to inpatient–outpatient communication in the care of stroke patients and found that clear communication is needed to ensure effective handoffs.

Journal Article > Commentary

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

Schreiber R, Sittig DF, Ash J, Wright A. J Am Med Inform Assoc. 2017 Feb 16; [Epub ahead of print].

Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.

Journal Article > Study

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

Novis DA, Lindholm PF, Ramsey G, Alcorn KW, Souers RJ, Blond B. Arch Pathol Lab Med. 2017;141:255-259.

The rate of mislabeled blood samples in hospital laboratories did not improve significantly between 2007 and 2015, despite widespread implementation of barcoding and other safety methods during that time period. An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary.

Journal Article > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Study

Improving communication with primary care physicians at the time of hospital discharge.

Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

Journal Article > Review

Year-end resident clinic handoffs: narrative review and recommendations for improvement.

Pincavage AT, Donnelly MJ, Young JQ, Arora VM. Jt Comm J Qual Patient Saf. 2017;43:71-79.

Year-end handoffs in residency training settings are a known patient safety risk. This narrative review found that several practices can enhance the safety of year-end transitions, including standardizing written and verbal signout for high-risk patients and enhancing attending-level supervision.

Journal Article

On Patient Safety.

Lee MJ. Clin Orthop Relat Res. 2013-2017.

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 work hour reforms. Older materials are available online for free.

Journal Article > Study

Large-scale implementation of the I-PASS handover system at an academic medical centre.

  • Classic

Shahian DM, McEachern K, Rossi L, Chisari RG, Mort E. BMJ Qual Saf. 2017 Mar 9; [Epub ahead of print].

Handoffs among providers remain suboptimal despite the development of effective strategies to improve them. This quality improvement report described the implementation of I-PASS, an evidence-based handoff strategy that has shown to reduce adverse events, at an academic medical center. Investigators utilized a comprehensive implementation strategy that included leadership support, training of all staff, integrating electronic health record templates to facilitate performance of I-PASS, and engaging frontline staff. This multi-faceted approach is similar to prior work implementing patient safety strategies. To evaluate the intervention, the researchers conducted surveys of clinicians and observed handoffs to determine if I-PASS was actually in use. They found that I-PASS was more consistently used on medical and pediatric services than on surgical services, where it was felt to be less applicable to stable postsurgical patients. The prevalence of asynchronous handoffs posed a barrier to consistent implementation. This report demonstrates the complexity of implementing and evaluating an evidence-based safety intervention and underscores the need for frontline staff involvement in improving safety.

Journal Article > Study

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

Bastawrous S, Carney B. J Digit Imaging. 2017;30:309-313.

Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Journal Article > Study

Association between end-of-rotation resident transition in care and mortality among hospitalized patients.

  • Classic

Denson JL, Jensen A, Saag HS, et al. JAMA. 2016;316:2204-2213.

Handoffs are ubiquitous in hospital care and a recognized risk factor for adverse events. Most research on handoffs has focused on care transitions from the primary clinician to a covering clinician, but studies have also demonstrated the potential for harm associated with changes in the entire team of care (such as at the end of the academic year). In academic hospitals, clinician teams switch on a predictable schedule, often at the end of the month, when residents complete a rotation. This study analyzed the outcomes of more than 200,000 inpatients at Veterans Affairs hospitals to determine if end-of-rotation team changes were associated with clinical harm. Investigators found a striking increase in in-hospital mortality among patients whose hospitalization spanned the end of a rotation (and thus were exposed to a resident team change during their hospital stay), which persisted for up to 90 days after discharge. The accompanying editorial notes that some of the mortality increase may be accounted for by the fact that patients who are more seriously ill and have longer hospitalizations may have been at higher risk of death independent of the team change. Nevertheless, since there are no standards for patient handoffs at the end of a rotation, poor information transfer or cognitive heuristics (such as anchoring bias) may have led to preventable adverse events. The editorial authors advocate for more research into the mechanisms of this mortality increase and the development of standards analogous to the I-PASS signout format for end-of-rotation handoffs.

Journal Article > Study

Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.

Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.

Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.

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