Patient Safety

Abstract Number: 234

STANDARDIZATION OF BEDSIDE PARACENTESIS

Background: In caring for hospitalized patients, hospitalists frequently perform bedside procedures. Shared decision-making, fluency in the procedure being performed, and consistent use of best practices are imperative for high quality, safe patient care. In review [...]

By | 2019-03-11T14:21:26+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on STANDARDIZATION OF BEDSIDE PARACENTESIS

Abstract Number: 229

TESTS PENDING AT TRANSITION FROM EMERGENCY DEPARTMENT TO INPATIENT ADMISSION: A SYSTEMS SOLUTION TO INCONSISTENT COMMUNICATION

Background: Tests Pending at Discharge (TPAD) is a common patient safety concern at transitions of care due to provider discontinuity, suboptimal communication, and lack of ownership. A significant proportion of inpatients, up to 70%, are [...]

By | 2019-03-11T14:21:18+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on TESTS PENDING AT TRANSITION FROM EMERGENCY DEPARTMENT TO INPATIENT ADMISSION: A SYSTEMS SOLUTION TO INCONSISTENT COMMUNICATION

Abstract Number: 222

STRUCTURED CASE REVIEWS FOR ORGANIZATIONAL LEARNING ABOUT DIAGNOSTIC SAFETY VULNERABILITIES: INITIAL EXPERIENCES FROM TWO MEDICAL CENTERS

Background: Increasing attention has been paid to diagnostic patient safety vulnerabilities, which account for 6 to 17% of hospital adverse events. In 2015, the National Academies of Medicine published a report on diagnostic safety errors, [...]

By | 2019-03-11T14:21:09+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on STRUCTURED CASE REVIEWS FOR ORGANIZATIONAL LEARNING ABOUT DIAGNOSTIC SAFETY VULNERABILITIES: INITIAL EXPERIENCES FROM TWO MEDICAL CENTERS

Abstract Number: 216

EMPHASIZING THE INITIAL PHYSICIAN ENCOUNTER ON ADMISSION RESULTS IN IMPROVED PATIENT SAFETY

Background: The first 24 hours of a patient’s hospitalization is a vulnerable time period, with many aspects of care occurring at a time when patients are at their highest levels of medical acuity. Compounding this, [...]

By | 2019-03-11T14:21:01+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on EMPHASIZING THE INITIAL PHYSICIAN ENCOUNTER ON ADMISSION RESULTS IN IMPROVED PATIENT SAFETY

Abstract Number: 215

NOVEL APPLICATION OF STRUCTURED CASE REVIEW TO IDENTIFY DIAGNOSTIC ERROR IN SEVEN-DAY READMISSIONS OF GENERAL MEDICAL PATIENTS

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days). A single prior study of early readmissions applied a binary (yes/no) metric to assess for [...]

By | 2019-03-11T14:20:59+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on NOVEL APPLICATION OF STRUCTURED CASE REVIEW TO IDENTIFY DIAGNOSTIC ERROR IN SEVEN-DAY READMISSIONS OF GENERAL MEDICAL PATIENTS

Abstract Number: 213

USE OF A WEB DASHBOARD TO IDENTIFY INR OVERSHOOTS IN HIGH-RISK INPATIENTS : A WARFARIN DOSING SAFETY INITIATIVE

Background: Anticoagulants are among the highest-risk medications in hospitalized patients. Studies have demonstrated that a majority of in-hospital anticoagulant adverse drug events are not only preventable, but are the result of excessive dosing. This is [...]

By | 2019-03-11T14:20:57+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on USE OF A WEB DASHBOARD TO IDENTIFY INR OVERSHOOTS IN HIGH-RISK INPATIENTS : A WARFARIN DOSING SAFETY INITIATIVE

Abstract Number: 211

HEPARIN INFUSION AFTER DIRECT ORAL ANTICOAGULANTS: STRATEGIES FOR IMPROVING QUALITY AND SAFETY OF ELECTRONIC ORDER SETS

Background: Hospitalized patients receiving direct oral anticoagulants (DOACs) sometimes require bridging with unfractionated heparin (UFH). Monitoring UFH with anti-Xa assays has been shown to correlate with better outcomes. However, DOACs interfere with anti-Xa assays resulting [...]

By | 2019-03-11T14:20:54+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on HEPARIN INFUSION AFTER DIRECT ORAL ANTICOAGULANTS: STRATEGIES FOR IMPROVING QUALITY AND SAFETY OF ELECTRONIC ORDER SETS

Abstract Number: 210

ADDRESSING DIAGNOSTIC ERRORS PROACTIVELY USING E-TRIGGERS TO MITIGATE HARM DURING INPATIENT EPISODES OF CARE

Background: Diagnostic error in acute care represents an unresolved safety issue: error rates range from 4.8 to 49.8%. If the diagnosis is delayed or incorrect, the patient may not get correct treatment in a timely [...]

By | 2019-03-11T14:20:52+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on ADDRESSING DIAGNOSTIC ERRORS PROACTIVELY USING E-TRIGGERS TO MITIGATE HARM DURING INPATIENT EPISODES OF CARE

Abstract Number: 207

SYSTEMATIC APPROACH TO HIGH YIELD MORTALITY CASE REVIEW

Background: Mortality review, well-documented in the medical literature, is a standardized process used to identify patient safety improvement opportunities and also to evaluate providers. As patient safety experts, hospitalists often review mortality cases for their [...]

By | 2019-03-11T14:20:48+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on SYSTEMATIC APPROACH TO HIGH YIELD MORTALITY CASE REVIEW

Abstract Number: 11

CARE PROCESS MODEL FOR OUR PATIENTS ADMITTED WITH MEDICAL COMPLICATIONS OF INJECTION DRUG MISUSE

Background: Beginning in 2015 Mission Hospital in Asheville, NC began noticing a rise in the number and associated length of stay (LOS) of patients admitted for medical complications of injection drug misuse. What began as [...]

By | 2019-03-18T13:26:36+00:00 March 11th, 2019|Finalist Posters - Innovations, Hospital Medicine 2019, Innovations, Patient Safety|Comments Off on CARE PROCESS MODEL FOR OUR PATIENTS ADMITTED WITH MEDICAL COMPLICATIONS OF INJECTION DRUG MISUSE