Patient Safety

/Tag: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: 439

SUPINE-RELATED ANEMIA IN HOSPITALIZED PATIENTS

Background: Hemoglobin and hematocrit, routinely measured in hospitalized patients, are likely affected by shifts in plasma volume related to posture. This could have important ramifications on hemoglobin trends overnight, resulting in over diagnosis of anemia [...]

By | 2019-03-11T14:26:27+00:00 March 11th, 2019|Hospital Medicine 2019, Research, Value in Hospital Medicine|Comments Off on SUPINE-RELATED ANEMIA IN HOSPITALIZED PATIENTS

Abstract Number: 435

THE MICHIGAN HOSPITAL MEDICINE SAFETY CONSORTIUM: IMPROVING PATIENT CARE BY REDUCING EXCESSIVE ANTIBIOTIC USE IN PATIENTS HOSPITALIZED WITH COMMUNITY-ACQUIRED PNEUMONIA

Background: Most patients hospitalized with community-acquired pneumonia (CAP) can be safely treated with 5-days of antibiotic therapy. However, many are not. We aimed to determine whether a hospitalist-focused collaborative could reduce excessive antibiotic use in [...]

By | 2019-03-11T14:26:21+00:00 March 11th, 2019|Hospital Medicine 2019, Research, Translating Research into Practice|Comments Off on THE MICHIGAN HOSPITAL MEDICINE SAFETY CONSORTIUM: IMPROVING PATIENT CARE BY REDUCING EXCESSIVE ANTIBIOTIC USE IN PATIENTS HOSPITALIZED WITH COMMUNITY-ACQUIRED PNEUMONIA

Abstract Number: 418

FROM HOSPITAL TO HOME: CREATING CARE TRANSITIONS STANDARDS FROM CONSENSUS USING NOMINAL GROUP TECHNIQUE

Background: The ACGME identifies care transitions as both a core competency and focus area for the Clinical Learning Environment Review, but there is a scarcity of literature on standardized curricula designed to teach residents how [...]

By | 2019-03-11T14:25:56+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Transitions of Care|Comments Off on FROM HOSPITAL TO HOME: CREATING CARE TRANSITIONS STANDARDS FROM CONSENSUS USING NOMINAL GROUP TECHNIQUE

Abstract Number: 388

AUGMENTED INTELLIGENCE: AUTOMATION OF VANCOMYCIN MONITORING TO IMPROVE PATIENT SAFETY

Background: Medical error is now the third leading cause of death in the United States. Approximately 4% of hospitalized patients experience an adverse event with 20% of these adverse events being medication-related, three-fourths of which [...]

By | 2019-03-11T14:25:11+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Technology in Hospital Medicine|Comments Off on AUGMENTED INTELLIGENCE: AUTOMATION OF VANCOMYCIN MONITORING TO IMPROVE PATIENT SAFETY

Abstract Number: 383

INTERACTIVE DIGITAL HEALTH TOOLS TO ENGAGE PATIENTS AND CAREGIVERS IN DISCHARGE PREPARATION: IMPLEMENTATION EXPERIENCE

Background: Sub-optimal discharge preparation during hospitalization may adversely impact safety and lead to a poor patient experience. As part of an AHRQ-funded study, we designed and developed interactive digital health tools (Figure 1) to engage [...]

By | 2019-03-11T14:25:04+00:00 March 11th, 2019|Hospital Medicine 2019, Research, Technology in Hospital Medicine|Comments Off on INTERACTIVE DIGITAL HEALTH TOOLS TO ENGAGE PATIENTS AND CAREGIVERS IN DISCHARGE PREPARATION: IMPLEMENTATION EXPERIENCE

Abstract Number: 337

ENGAGING HOSPITALISTS IN QUALITY IMPROVEMENT STRATEGIES FOR PRESSURE INJURY PREVENTION TO AVOID PATIENT HARM AND COSTLY PENALTIES

Background: Pressure injuries are tissue damage caused by pressure and shear. Susceptible patients are the elderly, acute, critically ill and malnourished. Pressure injuries severely deplete hospital performance measures in the U.S. Currently, over 2.5 million [...]

By | 2019-03-11T14:23:58+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Quality Improvement|Comments Off on ENGAGING HOSPITALISTS IN QUALITY IMPROVEMENT STRATEGIES FOR PRESSURE INJURY PREVENTION TO AVOID PATIENT HARM AND COSTLY PENALTIES

Abstract Number: 329

COMBINING LEAN SIX-SIGMA QUALITY IMPROVEMENT METHODS WITH SAFETY BARRIER ANALYSIS TO DEVELOP INTERVENTIONS THAT REDUCE HOSPITAL-ACQUIRED VENOUS THROMBOEMBOLISM (HA-VTE)

Background: The U.S. healthcare system has a poor safety record when compared to other major industries. For example, at 250,000 per year, medical errors are the 3rd leading cause of death according to the CDC. [...]

By | 2019-03-11T14:23:46+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Quality Improvement|Comments Off on COMBINING LEAN SIX-SIGMA QUALITY IMPROVEMENT METHODS WITH SAFETY BARRIER ANALYSIS TO DEVELOP INTERVENTIONS THAT REDUCE HOSPITAL-ACQUIRED VENOUS THROMBOEMBOLISM (HA-VTE)

Abstract Number: 328

CHARACTERIZING INAPPROPRIATE PROPHYLACTIC TRANSFUSION OF BLOOD PRODUCTS IN HOSPITALIZED PATIENTS UNDERGOING PARACENTESIS FROM 2004 TO 2012 IN THE UNITED STATES

Background: Patients with ascites due to cirrhosis frequently have some degree of thrombocytopenia and prolongation of prothrombin time. However, major bleeding rates from paracentesis are reported to be less than 1% without use of any [...]

By | 2019-03-11T14:23:45+00:00 March 11th, 2019|Hospital Medicine 2019, Quality Improvement, Research|Comments Off on CHARACTERIZING INAPPROPRIATE PROPHYLACTIC TRANSFUSION OF BLOOD PRODUCTS IN HOSPITALIZED PATIENTS UNDERGOING PARACENTESIS FROM 2004 TO 2012 IN THE UNITED STATES

Abstract Number: 299

IMPROVING COMMUNICATION OF DISCHARGE PLANS AMONGST RESIDENTS, NURSES, AND PATIENTS: A QUALITY IMPROVEMENT PROJECT

Background: Discharge of hospitalized patients is a multistep process, involving communication amongst numerous healthcare providers. Delays in discharge cause a backlog of patients in the ED and ICUs, leading to prolonged patient wait times and [...]

By | 2019-03-11T14:23:02+00:00 March 11th, 2019|Hospital Medicine 2019, Quality Improvement, Research|Comments Off on IMPROVING COMMUNICATION OF DISCHARGE PLANS AMONGST RESIDENTS, NURSES, AND PATIENTS: A QUALITY IMPROVEMENT PROJECT

Abstract Number: 297

RAPIDLY ENGAGING THE FRONTLINE: IMPLEMENTING A HOSPITALIST-LED, REAL-TIME, ELECTRONIC MORTALITY REVIEW PROCESS

Background: Traditional review approaches to inpatient mortality remain flawed. M&M conferences, administrative data analysis, and chart review do not effectively leverage the frontline perspective, are frequently delayed, and may be perceived as punitive if not [...]

By | 2019-03-11T14:23:00+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Quality Improvement|Comments Off on RAPIDLY ENGAGING THE FRONTLINE: IMPLEMENTING A HOSPITALIST-LED, REAL-TIME, ELECTRONIC MORTALITY REVIEW PROCESS

Abstract Number: 293

HOSPITAL MEDICINE MANAGEMENT OF PENDING TESTS AFTER DISCHARGE: A QUALITY IMPROVEMENT INTERVENTION

Background: Inpatient physicians often discharge patients while diagnostic tests are still pending. The discharging attending is responsible for following-up these results, even if they have rotated off service. This can lead to delayed and/or missed [...]

By | 2019-03-11T14:22:54+00:00 March 11th, 2019|Hospital Medicine 2019, Quality Improvement, Research|Comments Off on HOSPITAL MEDICINE MANAGEMENT OF PENDING TESTS AFTER DISCHARGE: A QUALITY IMPROVEMENT INTERVENTION

Abstract Number: 260

BEE QUIET: AN INNOVATIVE STRATEGY TO IMPROVE SLEEP QUALITY AND REDUCE FALLS

Background: Sleep disturbance has negative impact on physical coordination, metabolism, cognitive performance, immune function, coagulation cascade, cardiac risk and is associated with an increased risk of falls in hospitalized patients. The number of adverse events [...]

By | 2019-03-11T14:22:08+00:00 March 11th, 2019|Hospital Medicine 2019, Innovations, Quality Improvement|Comments Off on BEE QUIET: AN INNOVATIVE STRATEGY TO IMPROVE SLEEP QUALITY AND REDUCE FALLS

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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 38

THE VIRTUAL DISCHARGE WHITEBOARD: A REAL-TIME COMMUNICATION TOOL TO IMPROVE EFFICIENCY, SAFETY AND NURSE SATISFACTION SURROUNDING THE DISCHARGE PROCESS

Background: Discharging patients is a complicated process that requires planning, coordination and communication between multiple care team members. Ideally this process begins at admission and is updated in real time as the patient care plan [...]

By | 2019-03-11T14:16:52+00:00 March 11th, 2019|Communication, Hospital Medicine 2019, Innovations|Comments Off on THE VIRTUAL DISCHARGE WHITEBOARD: A REAL-TIME COMMUNICATION TOOL TO IMPROVE EFFICIENCY, SAFETY AND NURSE SATISFACTION SURROUNDING THE DISCHARGE PROCESS

Abstract Number: 27

PROFITING FROM THE POKE: A HOSPITALIST PROCEDURE TEAM

Background: Internal medicine residency contains procedural training, including guidance in paracentesis, thoracentesis, lumbar puncture, arthrocentesis, and central line placement. As a result, most hospitalists are able to perform these bedside procedures. However, national trends confirm [...]

By | 2019-03-18T14:09:57+00:00 March 11th, 2019|Finalist Posters - Innovations, Hospital Medicine 2019, Innovations, Value in Hospital Medicine|Comments Off on PROFITING FROM THE POKE: A HOSPITALIST PROCEDURE TEAM

HM2018 Abstract Number: Top 15 Research & Innovations

SAFETY QUEST: A NOVEL WEB-BASED GAME TO TEACH QI AND PATIENT SAFETY

Background: In 2016, ACGME’s first Clinical Learning Environment Review (CLER) report found that trainees had limited knowledge of Quality Improvement (QI) and patient safety (PS) concepts.. Purpose: We have designed a free, interactive, web-based game [...]

By | 2018-03-29T15:35:01+00:00 March 29th, 2018|Hospital Medicine 2018, Top 15 Research and Innovation Oral Abstracts|Comments Off on SAFETY QUEST: A NOVEL WEB-BASED GAME TO TEACH QI AND PATIENT SAFETY

HM2018 Abstract Number: Plenary presentation

MENTORED IMPLEMENTATION OF THE I-PASS HANDOFF PROGRAM IN DIVERSE CLINICAL ENVIRONMENTS

Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives [...]

By | 2018-03-29T15:34:50+00:00 March 29th, 2018|Hospital Medicine 2018, Plenary Presentations|Comments Off on MENTORED IMPLEMENTATION OF THE I-PASS HANDOFF PROGRAM IN DIVERSE CLINICAL ENVIRONMENTS

HM2018 Abstract Number: 155

Measuring and Reporting Central Line-Associated Bloodstream Infection: More Than Meets the Eye?

Background: Although central line-associated bloodstream infection (CLABSI) rates are publicly reported, whether these data correlate to clinical documentation or practice is not known. Using data from a large hospital collaborative, we hypothesized that physician [...]

By | 2018-03-21T16:17:45+00:00 March 19th, 2018|Patient Safety, Research, Uncategorized|Comments Off on Measuring and Reporting Central Line-Associated Bloodstream Infection: More Than Meets the Eye?

HM2018 Abstract Number: 497

An Unnecessary Procedure in a Sickle Cell Patient with Acute Chest Syndrome

Case Presentation: A 28-year-old woman with sickle cell disease and chronic pain who required inpatient care several times yearly presented with worsening nausea, emesis and uncontrolled pain to the emergency department (ED). Symptoms were typical [...]

By | 2018-03-19T15:43:54+00:00 March 19th, 2018|Adult, Clinical Vignettes, Uncategorized|Comments Off on An Unnecessary Procedure in a Sickle Cell Patient with Acute Chest Syndrome

HM2018 Abstract Number: 215

Development and Implementation of an Electronic Health Record based Medication Reconciliation Risk Stratification Tool to Optimally Deploy Limited Pharmacy Resources

Background: Medication errors occur frequently at transitions of care and lead to significant patient harm. Robust medication reconciliation practices can mitigate these errors, but this process is complex and time-consuming. One of the conclusions of [...]

By | 2018-03-19T15:44:21+00:00 March 19th, 2018|Innovations, Quality Improvement, Uncategorized|Comments Off on Development and Implementation of an Electronic Health Record based Medication Reconciliation Risk Stratification Tool to Optimally Deploy Limited Pharmacy Resources

HM2018 Abstract Number: 237

IMPROVING RESPIRATORY RATE MEASUREMENT ACCURACY IN THE HOSPITAL: A QUALITY IMPROVEMENT INITIATIVE

Background: Respiratory rate (RR) is a predictor of adverse outcomes and an integral component of many risk prediction scores for hospitalized adults. Despite its clinical value, RRs are often inaccurate and may lead to misclassification [...]

By | 2018-03-19T15:44:22+00:00 March 19th, 2018|Innovations, Quality Improvement, Uncategorized|Comments Off on IMPROVING RESPIRATORY RATE MEASUREMENT ACCURACY IN THE HOSPITAL: A QUALITY IMPROVEMENT INITIATIVE

HM2018 Abstract Number: 174

IMPROVING PATIENT SAFETY OUTCOMES AMONG PATIENTS TRANSFERRED FROM AN OUTSIDE FACILITY: A QUALITY IMPROVEMENT PROJECT

Background: Advances in technology and life-sustaining interventions afford patients access to a wider network of subspecialized care through inter-facility transfers. Implicit in these transfers are multiple complex steps that leave patients vulnerable to adverse events. [...]

By | 2018-03-19T15:44:42+00:00 March 19th, 2018|Innovations, Patient Safety, Uncategorized|Comments Off on IMPROVING PATIENT SAFETY OUTCOMES AMONG PATIENTS TRANSFERRED FROM AN OUTSIDE FACILITY: A QUALITY IMPROVEMENT PROJECT

HM2018 Abstract Number: 158

An Interdisciplinary Team to Support Implementation of a “System-of-Systems” to Identify, Assess, and Mitigate Threats to Patient Safety in Real-Time

Background: Implementing technology with the goal of eliminating preventable hospital-acquired conditions (e.g., CAUTI, CLABSI, etc.) in the acute care setting is an ongoing challenge, but it is crucial to creating a safer healthcare system. Increasingly, [...]

By | 2018-03-19T13:24:46+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Patient Safety|Comments Off on An Interdisciplinary Team to Support Implementation of a “System-of-Systems” to Identify, Assess, and Mitigate Threats to Patient Safety in Real-Time

HM2018 Abstract Number: 266

MEDICATION RECONCILIATION: REC IT RIGHT, SO IT’S NOT A WRECK

Background: The Joint Commission (TJC) included medication reconciliation (MedRec) as a 2005 National Patient Safety Goal to reduce errors related to medication omissions, duplications and interactions. Medication errors and harms continue to be one of [...]

By | 2018-03-19T13:24:33+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Quality Improvement|Comments Off on MEDICATION RECONCILIATION: REC IT RIGHT, SO IT’S NOT A WRECK

HM2018 Abstract Number: 71

An Interdisciplinary Approach to Quality Improvement on the Inpatient Teaching Unit

Background: Interdisciplinary communication, quality improvment, and patient safety, are integral components to providing quality healthcare. Furthermore, the ACGME recognizes the importance of the learning and working environment, a culture of safety, and providing opportunities for [...]

By | 2018-03-19T13:23:02+00:00 March 19th, 2018|Education, Hospital Medicine 2018, Innovations|Comments Off on An Interdisciplinary Approach to Quality Improvement on the Inpatient Teaching Unit

HM2018 Abstract Number: 55

A HYPOTENSION GROUP OBSERVED STANDARDIZED CLINICAL ENCOUNTER: ESTABLISHING A CULTURE OF PATIENT SAFETY FOR NEW INTERNS

Background: Incoming interns must understand the specific culture of safety at their new institution as well as processes that they are expected to know on day 1 of residency. As part of an immersive half-day [...]

By | 2018-03-19T13:16:56+00:00 March 19th, 2018|Education, Hospital Medicine 2018, Research|Comments Off on A HYPOTENSION GROUP OBSERVED STANDARDIZED CLINICAL ENCOUNTER: ESTABLISHING A CULTURE OF PATIENT SAFETY FOR NEW INTERNS

HM2018 Abstract Number: 56

A SIMULATED FIRST NIGHT ON CALL: ESTABLISHING COMMUNITY AND A CULTURE OF PATIENT SAFETY FOR INCOMING INTERNS

Background: The transition from medical student to intern presents a major patient safety concern. Incoming interns must understand the specific culture of safety at their new institution and processes that they are expected to perform [...]

By | 2018-03-19T13:16:51+00:00 March 19th, 2018|Education, Hospital Medicine 2018, Research|Comments Off on A SIMULATED FIRST NIGHT ON CALL: ESTABLISHING COMMUNITY AND A CULTURE OF PATIENT SAFETY FOR INCOMING INTERNS

HM2018 Abstract Number: 324

THE IMPACT OF HEALTH LITERACY ON 30-DAY READMISSIONS AT A TERTIARY CARE ACADEMIC MEDICAL CENTER

Background: Health literacy (HL) is the measure of a person’s ability to obtain, process and understand basic health information and services to make appropriate health decisions.1 Previous studies note positive correlation between high HL and [...]

By | 2018-03-19T13:08:09+00:00 March 19th, 2018|Hospital Medicine 2018, Research, Transitions of Care|Comments Off on THE IMPACT OF HEALTH LITERACY ON 30-DAY READMISSIONS AT A TERTIARY CARE ACADEMIC MEDICAL CENTER

HM2018 Abstract Number: 159

Effectiveness of rapid response system to identify critically ill patients in an outpatient setting.

Background: Rapid response system (RRS) was developed in recent decades for the timely identification and treatment of clinically deteriorating patients. Appropriate use of RRS will decrease the incidence of cardiac arrest and mortality. Although efficacy [...]

By | 2018-03-19T13:07:04+00:00 March 19th, 2018|Hospital Medicine 2018, Patient Safety, Research|Comments Off on Effectiveness of rapid response system to identify critically ill patients in an outpatient setting.

HM2018 Abstract Number: 231

PARTNERS IN QUALITY: ENHANCING RESIDENT EDUCATION AND INSTITUTIONAL INITIATIVES BY EMBEDDING PERFORMANCE IMPROVEMENT SPECIALISTS INTO A PATIENT SAFETY AND QUALITY IMPROVEMENT CURRICULUM

Background: An effective patient safety and quality improvement (QI) curriculum is imperative for graduate medical education (GME) training programs. Yet many health systems are lacking pedagogical training in these methods. Learning often takes the form [...]

By | 2018-03-19T13:03:48+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Quality Improvement|Comments Off on PARTNERS IN QUALITY: ENHANCING RESIDENT EDUCATION AND INSTITUTIONAL INITIATIVES BY EMBEDDING PERFORMANCE IMPROVEMENT SPECIALISTS INTO A PATIENT SAFETY AND QUALITY IMPROVEMENT CURRICULUM

HM2018 Abstract Number: 161

SHINING LIGHT ON THE BLACK BOX OF ERROR REPORTING: DEVELOPMENT OF AN INTERPROFESSIONAL SAFETY HUDDLE

Background: New ACGME Core requirements require active resident engagement in patient safety. Our institution’s most recent AHRQ Culture of Safety survey revealed poor ratings from residents for closed-loop feedback on event reports they had submitted. [...]

By | 2018-03-19T13:03:02+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Patient Safety|Comments Off on SHINING LIGHT ON THE BLACK BOX OF ERROR REPORTING: DEVELOPMENT OF AN INTERPROFESSIONAL SAFETY HUDDLE

HM2018 Abstract Number: 164

VASCULAR ACCESS STEWARDSHIP: ENHANCING PATIENT SAFETY ONE (LESS) LINE AT A TIME

Background: Peripherally inserted central catheters (PICCs) are routinely placed in hospitalized patients who are receiving long-term IV antibiotics or who have poor venous access. In our hospital, 1 in 12 patients on the Medicine service [...]

By | 2018-03-19T12:59:36+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Patient Safety|Comments Off on VASCULAR ACCESS STEWARDSHIP: ENHANCING PATIENT SAFETY ONE (LESS) LINE AT A TIME

HM2018 Abstract Number: 77

SIMULATION STRATEGIES TO TEACH NON-OPERATING ROOM PROCEDURAL TIME-OUTS: A RANDOMIZED CONTROL TRIAL

Background: Nearly half of incorrect procedures occur outside the operating room, and failure to conduct a robust time-out is a frequent root cause. Mannequin-based simulation (MBS) has been shown to improve self-confidence and performance of [...]

By | 2018-03-19T12:58:20+00:00 March 19th, 2018|Education, Hospital Medicine 2018, Research|Comments Off on SIMULATION STRATEGIES TO TEACH NON-OPERATING ROOM PROCEDURAL TIME-OUTS: A RANDOMIZED CONTROL TRIAL

HM2018 Abstract Number: 153

HELP ME, OBI-WAN KENOBI: IMPROVING PATIENT SAFETY REPORTING BY RESIDENTS WITH RESIDENT-LED PATIENT SAFETY ROUNDS AND PEER COACHING

Background: Residents, because they are on the frontlines of the provision of care, are integral to improving care. Yet the Accreditation Council for Graduate Medical Education (ACGME) has reported residents are not as engaged in [...]

By | 2018-03-19T12:53:32+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Patient Safety|Comments Off on HELP ME, OBI-WAN KENOBI: IMPROVING PATIENT SAFETY REPORTING BY RESIDENTS WITH RESIDENT-LED PATIENT SAFETY ROUNDS AND PEER COACHING

HM2018 Abstract Number: 165

INTER-PROFESSIONAL QUALITY IMPROVEMENT PROJECT TO IMPROVE THE SAFETY OF DISCHARGE MEDICATION RECONCILIATION PROCESS FOR HOSPITALIZED PATIENTS

Background: Accurate medication reconciliation during transitions of care can decrease medication related adverse drug events. The Joint Commission has prioritized medication reconciliation as one of the national patient safety goals. Effective pharmacist-physician-patient collaboration can improve [...]

By | 2018-03-19T12:53:02+00:00 March 19th, 2018|Hospital Medicine 2018, Innovations, Patient Safety|Comments Off on INTER-PROFESSIONAL QUALITY IMPROVEMENT PROJECT TO IMPROVE THE SAFETY OF DISCHARGE MEDICATION RECONCILIATION PROCESS FOR HOSPITALIZED PATIENTS

HM2017 Abstract Number: 223

DOES INCREASED CLINICAL WORKLOAD LEAD TO POORER PERFORMANCE ON QUALITY IMPROVEMENT INDICATORS?

Background: A “safe” hospitalist workload - that is, the point at which caring for too many patients leads to poorer outcomes for each individual patient – has not been defined.  We sought to understand whether [...]

By | 2017-04-26T02:46:42+00:00 April 20th, 2017|Quality Improvement, Research Abstracts|Comments Off on DOES INCREASED CLINICAL WORKLOAD LEAD TO POORER PERFORMANCE ON QUALITY IMPROVEMENT INDICATORS?

HM2017 Abstract Number: 106

PILOT OF A LOW-RESOURCE, EHR-BASED TOOL FOR SEPSIS MONITORING, ALERT, AND INTERVENTION

Background: Sepsis is a common, costly, and mortal clinical syndrome. Many delays in sepsis recognition and intervention are due to “data latency,” the period of time between data suggestive of sepsis being entered in the [...]

By | 2017-04-20T17:23:49+00:00 April 20th, 2017|Innovations Abstracts, Patient Safety|Comments Off on PILOT OF A LOW-RESOURCE, EHR-BASED TOOL FOR SEPSIS MONITORING, ALERT, AND INTERVENTION

HM2016 Abstract Number: 188

Venous Thromboembolism After Hospitalization in Trauma Patients: Does Prophylaxis Matter?

Background: Venous thromboembolism (VTE), both pulmonary embolism (PE) and deep vein thrombosis (DVT), causes morbidity and mortality in hospitalized patients. The duration of VTE risk in trauma, particularly after discharge, is not well understood, especially [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Perioperative, Research Abstracts|Comments Off on Venous Thromboembolism After Hospitalization in Trauma Patients: Does Prophylaxis Matter?

HM2016 Abstract Number: 166

Hospital Horror Story: Situational Awareness to Assess Interns’ Recognition of Safety and Low-Value Hospital Hazards

Background:  While many institutions train housestaff to mitigate hospital hazards, few have exploited the crucial concept of situational awareness (i.e. mindfulness of the patient environment) to teach patient safety. One method to promote situational awareness [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Patient Safety|Comments Off on Hospital Horror Story: Situational Awareness to Assess Interns’ Recognition of Safety and Low-Value Hospital Hazards

HM2016 Abstract Number: 150

Pilot of a Low-Resource, Ehr-Based Protocol for Sepsis Monitoring, Alert, and Intervention

Background: In-hospital mortality attributable to sepsis is higher than overall population mortality (Gaieski DF et al, 2013; Dombrovskiy VY, 2007). Furthermore, the rates of severe sepsis are increasing annually (Dombrovskiy VY,2007). Early detection and early [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Patient Safety|Comments Off on Pilot of a Low-Resource, Ehr-Based Protocol for Sepsis Monitoring, Alert, and Intervention

HM2016 Abstract Number: 148

An Electronic Health Record-Based Severe Sepsis Alert to Improve Sepsis Treatment Performance: Randomized Evaluation

Background: Sepsis, severe sepsis, and septic shock combined, are estimated to affect between 650,000 and 750,000 Americans annually, and has an associated mortality rate between 20 to 50%.  Early identification of patients with sepsis is [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Finalist, Patient Safety, Research Abstracts|Comments Off on An Electronic Health Record-Based Severe Sepsis Alert to Improve Sepsis Treatment Performance: Randomized Evaluation

HM2016 Abstract Number: 147

Creation and Growth of a Hospitalist-Led Medicine Procedure Service: A 2-Year Experience

Background: The American Board of Internal Medicine expects all general internists to be competent, at least “with regard to their knowledge and understanding,” in bedside paracentesis, thoracentesis, central venous catheterization, and lumbar puncture, among other [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Patient Safety|Comments Off on Creation and Growth of a Hospitalist-Led Medicine Procedure Service: A 2-Year Experience

HM2016 Abstract Number: 113

Impact of Admission Nursing Team on Timely Inpatient Discharge in Acute Hospital Care Setting

Background: Emergency Department (ED) overcrowding and delays in ED throughput have several important consequences , such as boarding of admitted patients in the ED, longer hospital stays and delay in effective inpatient discharge planning (1). [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Outcomes Research, Research Abstracts|Comments Off on Impact of Admission Nursing Team on Timely Inpatient Discharge in Acute Hospital Care Setting

HM2016 Abstract Number: 30

Honing the Sharp End: A Resident Rotation in Patient Safety and Quality Improvement

Background: The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review (CLER) program has placed a much-needed spotlight on the role of resident physicians in patient safety (PS) and quality improvement (QI). Medical school [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Education, Innovations Abstracts|Comments Off on Honing the Sharp End: A Resident Rotation in Patient Safety and Quality Improvement