Patient Safety

Abstract Number: Oral

THE PREVALENCE OF 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), but little is known about their frequency and characteristics. We performed structured chart review of [...]

By | 2019-03-12T15:50:33+00:00 March 11th, 2019|Hospital Medicine 2019, Oral Presentations, Patient Safety, Research|Comments Off on THE PREVALENCE OF DIAGNOSTIC ERROR IN SEVEN-DAY READMISSIONS OF GENERAL MEDICAL PATIENTS

Abstract Number: 236

THE “JULY EFFECT” ON HOSPITAL DEATHS FROM ACUTE MYOCARDIAL INFARCTION: MYTH OR REALITY?

Background: The "July effect" is a perceived increased risk of medical errors that occurs when US medical graduates begin residencies. There is substantial variability in results across studies of the "July effect" on patients who [...]

By | 2019-03-11T14:21:29+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on THE “JULY EFFECT” ON HOSPITAL DEATHS FROM ACUTE MYOCARDIAL INFARCTION: MYTH OR REALITY?

Abstract Number: 235

ANTIBIOTIC STEWARDSHIP TEAMS AND CLOSTRIDIOIDES DIFFICILE INFECTION PREVENTION PRACTICES IN UNITED STATES HOSPITALS: A NATIONAL SURVEY IN THE JOINT COMMISSION ANTIMICROBIAL STEWARDSHIP STANDARD ERA

Background: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. We found in a 2013 national survey (571 hospitals, 71% response rate) that while infection prevention practices for CDI were [...]

By | 2019-03-11T14:21:27+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on ANTIBIOTIC STEWARDSHIP TEAMS AND CLOSTRIDIOIDES DIFFICILE INFECTION PREVENTION PRACTICES IN UNITED STATES HOSPITALS: A NATIONAL SURVEY IN THE JOINT COMMISSION ANTIMICROBIAL STEWARDSHIP STANDARD ERA

Abstract Number: 233

PAIN ASSESSMENT TOOLS IN PATIENTS WITH CHRONIC OPIOD USE: A SYSTEMATIC REVIEW

Background: It is often challenging to assess pain in patients on chronic opioids either in acute care setting or in outpatient centers. Pain assessment in this group is more challenging especially if they are hospitalized [...]

By | 2019-03-11T14:21:24+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on PAIN ASSESSMENT TOOLS IN PATIENTS WITH CHRONIC OPIOD USE: A SYSTEMATIC REVIEW

Abstract Number: 232

ARE MIDLINES SAFER THAN PICCS IN HOSPITALIZED PATIENTS? COMPARISON OF OUTCOMES OF PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCS) VS MIDLINES FROM A STATEWIDE COLLABORATIVE

Background: Midlines are peripheral vascular devices inserted in the veins of the upper extremity with the tip located at or below the axillary vein. Complications associated with peripherally inserted central catheter (PICC) along with documented [...]

By | 2019-03-11T14:21:23+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on ARE MIDLINES SAFER THAN PICCS IN HOSPITALIZED PATIENTS? COMPARISON OF OUTCOMES OF PERIPHERALLY INSERTED CENTRAL CATHETERS (PICCS) VS MIDLINES FROM A STATEWIDE COLLABORATIVE

Abstract Number: 231

ADVERSE EVENTS EXPERIENCED BY PATIENTS HOSPITALIZED WITHOUT DEFINITE MEDICAL ACUITY: A RETROSPECTIVE COHORT STUDY

Background: There is evidence that physicians consider a variety of “non-medical” factors (e.g. lack of social support, barriers to access) in hospital admission decision-making out of concern for patient safety, and that patients are hospitalized [...]

By | 2019-03-11T14:21:21+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on ADVERSE EVENTS EXPERIENCED BY PATIENTS HOSPITALIZED WITHOUT DEFINITE MEDICAL ACUITY: A RETROSPECTIVE COHORT STUDY

Abstract Number: 230

SAFETY OF ANTIMOLITY AGENT USE DURING TREATMENT FOR CLOSTRIDIOIDES DIFFICILE INFECTION IN MALIGNANT HEMATOLOGY INPATIENTS

Background: Guidelines on the treatment of Clostridioides (Clostridium) difficile infection (CDI) have historically recommended avoiding antimotility agents (AAs) in patients with active CDI based on theoretical concerns that administration of AAs may precipitate serious adverse [...]

By | 2019-03-11T14:21:20+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on SAFETY OF ANTIMOLITY AGENT USE DURING TREATMENT FOR CLOSTRIDIOIDES DIFFICILE INFECTION IN MALIGNANT HEMATOLOGY INPATIENTS

Abstract Number: 228

RIFAXIMIN ALONE VERSUS RIFAXIMIN AND LACTULOSE COMBINATION THERAPY FOR PREVENTION OF OVERT HEPATIC ENCEPHALOPATHY RECURRENCE: SAFETY PROFILE IN PATIENTS WITH CIRRHOSIS

Background: Rifaximin 550 mg tablets is a nonsystemic antibiotic indicated for reducing the risk of overt hepatic encephalopathy (OHE) recurrence in adults and may be used alone or in combination with the cathartic lactulose. This [...]

By | 2019-03-11T14:21:17+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on RIFAXIMIN ALONE VERSUS RIFAXIMIN AND LACTULOSE COMBINATION THERAPY FOR PREVENTION OF OVERT HEPATIC ENCEPHALOPATHY RECURRENCE: SAFETY PROFILE IN PATIENTS WITH CIRRHOSIS

Abstract Number: 227

FREQUENCY OF INPATIENT DEATHS DUE TO MEDICAL ERROR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Since the publication of the Institute of Medicine report To Err Is Human in 1999, preventable inpatient deaths in the United States have been estimated as between 44,000 and 98,000 deaths annually. A more [...]

By | 2019-03-11T14:21:16+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on FREQUENCY OF INPATIENT DEATHS DUE TO MEDICAL ERROR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Number: 226

PATIENTS’ ACCEPTANCE OF INCORPORATING THEIR PHOTOGRAPH INTO THE ELECTRONIC HEALTH RECORD

Background: Wrong-patient order entry errors are common and often have the potential to cause patient harm. The Office of the National Coordinator for Health Information Technology Patient Identification SAFER Guide recommends displaying patient photographs in [...]

By | 2019-03-11T14:21:14+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on PATIENTS’ ACCEPTANCE OF INCORPORATING THEIR PHOTOGRAPH INTO THE ELECTRONIC HEALTH RECORD

Abstract Number: 225

DO HOSPITALIZED PATIENTS RECEIVE APPROPRIATE VENOUS THROMBOEMBOLISM PROPHYLAXIS?

Background: Medical patients can be risk stratified using the Padua Prediction Score for venous thromboembolism (vte). It is important to then use the appropriate prophylaxis, chemical, mechanical or none. Studies have not found an added [...]

By | 2019-03-11T14:21:13+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on DO HOSPITALIZED PATIENTS RECEIVE APPROPRIATE VENOUS THROMBOEMBOLISM PROPHYLAXIS?

Abstract Number: 224

WHO YOU GONNA CALL? OUTCOMES OF AN INTERVENTION DESIGNED TO RESPOND TO ACUTE DISRUPTIVE PATIENT BEHAVIORAL EPISODES.

Background: The behavioral response team (BRT) at UNC Hospitals was established in 2015 and its purpose is to bring immediate resources to bear when hospitalized patients experience acute episodes of disruptive behavior that may cause [...]

By | 2019-03-11T14:21:12+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on WHO YOU GONNA CALL? OUTCOMES OF AN INTERVENTION DESIGNED TO RESPOND TO ACUTE DISRUPTIVE PATIENT BEHAVIORAL EPISODES.

Abstract Number: 223

EMERGENCIES IN DIALYSIS: A RETROSPECTIVE REVIEW OF MEDICAL EMERGENCY TEAM UTILIZATION IN HOSPITALIZED PATIENTS WITH END-STAGE RENAL DISEASE

Background: Medical Emergency Teams (METs) are utilized in an inpatient setting to identify patients who exhibit signs of clinical deterioration. Patients, family, or staff activate the team by calling a Code MET when there is [...]

By | 2019-03-11T14:21:10+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on EMERGENCIES IN DIALYSIS: A RETROSPECTIVE REVIEW OF MEDICAL EMERGENCY TEAM UTILIZATION IN HOSPITALIZED PATIENTS WITH END-STAGE RENAL DISEASE

Abstract Number: 221

SUPPORT OPPORTUNITIES FOR SECOND VICTIMS (SOS)

Background: The phrase “Second Victim” describes the psychological/emotional trauma healthcare providers experience after being involved in a near-miss, minor or serious medical error, or unanticipated adverse patient outcome. Affected providers report feelings of guilt, anger, [...]

By | 2019-03-11T14:21:08+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on SUPPORT OPPORTUNITIES FOR SECOND VICTIMS (SOS)

Abstract Number: 220

IDENTIFYING RISK FACTORS FOR HYPOGLYCEMIA TO PREVENT ADVERSE OUTCOMES AMONG HOSPITALIZED PATIENTS

Background: Diabetes affects 30.3 million people in the US, and 25% of total hospital days are incurred by patients with diabetes. Among hospitalized adults, diabetes is considered a chronic secondary diagnosis. As the population of [...]

By | 2019-03-11T14:21:06+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on IDENTIFYING RISK FACTORS FOR HYPOGLYCEMIA TO PREVENT ADVERSE OUTCOMES AMONG HOSPITALIZED PATIENTS

Abstract Number: 219

ASSESSING DOCUMENTATION OF CLINICAL REASONING IN ADMISSION NOTES OF PHYSICIANS WORKING IN HOSPITAL MEDICINE

Background: High quality clinical documentation is essential for patient safety. Thoughtful clinical documentation transmits one’s clinical reasoning and is considered to be a professional responsibility. There are no accepted standards for assessing documentation with respect [...]

By | 2019-03-11T14:21:05+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on ASSESSING DOCUMENTATION OF CLINICAL REASONING IN ADMISSION NOTES OF PHYSICIANS WORKING IN HOSPITAL MEDICINE

Abstract Number: 218

TITLE: REAL TIME INTERVIEWS TO INVESTIGATE WRONG-PATIENT ERRORS DESPITE PATIENT PHOTOGRAPHS

Background: The electronic health record (EHR) and health care provider workflow process may contribute to patient misidentification or wrong-patient errors. When self-caught by the provider, these errors are classified as near-miss errors. When these errors [...]

By | 2019-03-11T14:21:03+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on TITLE: REAL TIME INTERVIEWS TO INVESTIGATE WRONG-PATIENT ERRORS DESPITE PATIENT PHOTOGRAPHS

Abstract Number: 217

THE EFFICACY OF MULTIMODAL APPROACH TO REDUCE UNNECESSARY URINARY CATHETER USE, A PILOT STUDY IN JAPAN.

Background: Catheter-associated urinary tract infection (CAUTI) is a common and clinically important hospital-associated infection throughout the world. A few data from Japan exist regarding the prevalence and appropriateness of urinary catheters in hospitalized patients but [...]

By | 2019-03-11T14:21:02+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on THE EFFICACY OF MULTIMODAL APPROACH TO REDUCE UNNECESSARY URINARY CATHETER USE, A PILOT STUDY IN JAPAN.

Abstract Number: 214

I-PSI: A CAMPAIGN TO INCREASE PATIENT SAFETY REPORTING BY HOUSESTAFF

Background: Voluntary incident reporting systems are an essential component of a high reliability organization (HRO). Historically, housestaff contribute just 1% of all patient safety intelligence (PSI) events reported at our tertiary care academic institution. This [...]

By | 2019-03-11T14:20:58+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on I-PSI: A CAMPAIGN TO INCREASE PATIENT SAFETY REPORTING BY HOUSESTAFF

Abstract Number: 212

IMPLEMENTATION OF AN EARLY WARNING SYSTEM IMPROVES PATIENT SAFETY, BUT IS IT WORTH THE COSTS?

Background: Numerous early warning systems (EWS) exist as potential tools to improve patient safety. Our system recognized higher than peer rates of rapid response (RRT) utilization as well as higher than desired out-of-ICU code blue [...]

By | 2019-03-11T14:20:55+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on IMPLEMENTATION OF AN EARLY WARNING SYSTEM IMPROVES PATIENT SAFETY, BUT IS IT WORTH THE COSTS?

Abstract Number: 209

VARIATION IN USE AND OUTCOMES OF MIDLINE CATHETERS: A MULTI-CENTER STUDY

Background: Midline vascular catheters are gaining popularity in clinical practice. However, patterns of use and outcomes related to these devices are not well known.Methods: Trained abstractors collected detailed patient-, device- and outcome data from medical [...]

By | 2019-03-11T14:20:51+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on VARIATION IN USE AND OUTCOMES OF MIDLINE CATHETERS: A MULTI-CENTER STUDY

Abstract Number: 208

PATTERNS OF PERIPHERALLY INSERTED CENTRAL CATHETER USE IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Background: Peripherally inserted central catheter (PICC) use in patients with chronic kidney disease (CKD) is associated with non-functioning arteriovenous fistulae. Existing guidelines recommend avoiding PICC placement in these patients but how often this occurs and [...]

By | 2019-03-11T14:20:49+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on PATTERNS OF PERIPHERALLY INSERTED CENTRAL CATHETER USE IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Number: 206

BAD MEDICINE: MEDICAL ERROR IN MEDICAL TELEVISION DRAMAS

Background: Since 1951, medical television dramas have impacted how the public views, understands, and learns about the medical profession. Previous studies have examined how these shows depict topics such as cardiopulmonary resuscitation; other studies have [...]

By | 2019-03-11T14:20:46+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on BAD MEDICINE: MEDICAL ERROR IN MEDICAL TELEVISION DRAMAS

Abstract Number: 205

USE AND PERCEIVED USABILITY OF A PATIENT SAFETY DASHBOARD

Background: Adverse events (AEs) are a major concern in the inpatient setting, with many considered preventable. The Patient Safety Learning Lab implemented a Patient Safety Dashboard integrated with our electronic health record as part of [...]

By | 2019-03-11T14:20:43+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on USE AND PERCEIVED USABILITY OF A PATIENT SAFETY DASHBOARD

Abstract Number: 204

THE EFFECTS OF A SUITE OF HEALTH INFORMATION TECHNOLOGY TOOLS TO IMPROVE INPATIENT SAFETY ON PROCESSES OF CARE

Background: Health information technology (HIT) has the potential to decrease rates of hospital-acquired conditions. The Patient Safety Learning Lab (PSLL) developed a suite of HIT tools to engage patients, families, and providers in identifying, assessing, [...]

By | 2019-03-11T14:20:38+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on THE EFFECTS OF A SUITE OF HEALTH INFORMATION TECHNOLOGY TOOLS TO IMPROVE INPATIENT SAFETY ON PROCESSES OF CARE

Abstract Number: 203

DO CLINICIANS KNOW WHICH OF THEIR PATIENTS HAVE PERIPHERAL INTRAVENOUS CATHETERS?

Background: Peripheral Intravenous Catheters (PIVs) are the most frequently used invasive device in hospitalized patients. Although they are often considered low risk, complications associated with peripheral IVs include phlebitis, bloodstream infection, extravasation. They are also [...]

By | 2019-03-11T14:20:37+00:00 March 11th, 2019|Hospital Medicine 2019, Patient Safety, Research|Comments Off on DO CLINICIANS KNOW WHICH OF THEIR PATIENTS HAVE PERIPHERAL INTRAVENOUS CATHETERS?

Abstract Number: 10

APPLYING MAGIC TO IMPROVE PICC APPROPRIATENESS IN 42 MICHIGAN HOSPITALS

Background: A substantial proportion of peripherally inserted central catheters (PICCs) are placed for inappropriate indications. We performed a multi-hospital intervention to improve the appropriateness of PICC use.Methods: We conducted a collaborative cohort study of hospitals [...]

By | 2019-03-18T13:25:43+00:00 March 11th, 2019|Finalist Posters - Research, Hospital Medicine 2019, Patient Safety, Research|Comments Off on APPLYING MAGIC TO IMPROVE PICC APPROPRIATENESS IN 42 MICHIGAN HOSPITALS