Background: Interdisciplinary rounds are widely recommended to improve communication, reduce care fragmentation, and enhance discharge efficiency. However, their effectiveness varies depending on structure, workflow alignment, and discipline engagement. In 2024, our health system implemented a standardized Structured Interdisciplinary Rounds (POCR) model across few inpatient medical units. The model included a structured script, a unified flow [...]

Background: Diagnostic error (DE) matters in medical safety, threatening high-quality care. The frequency of DE is known to differ among each disease, and that of pulmonary embolism (PE) is estimated as 18-38%. While PE is recognized as a crucial pathology in DE, little is known about attributable factors in errors of PE. This research attempted [...]

Background: Discharge from the inpatient hospital setting against medical advice (AMA) poses significant challenges to continuity of care and portends increased risk of 30-day readmission and all-cause mortality. However, there are no practice guidelines for management of a patient who wishes to leave AMA and limited data is available on the clinical characteristics of such [...]

Background: Hospital-at-Home (HaH) programs represent an innovative model of healthcare delivery that has gained traction across the U.S. over the past decade. Multiple studies have shown that HaH provides comparable or superior 30-day mortality, readmission rates, and overall outcomes compared to traditional brick-and-mortar (BaM) hospitals. While HaH has been demonstrated to safely manage some acute [...]

Background: The Safety I diagnosis framework primarily evaluates underlying causes of adverse events, tacitly assuming that system components either work or do not work.(1) By contrast, the Safety II diagnosis framework evaluates how performance goes as expected, which starts from a “work as imagined” and moves to “work as done”. The aims of this study [...]

Background: Large academic medical centers (AMCs) increasingly rely on interfacility transfers to affiliated community sites to optimize bed capacity and resource allocation. Despite this trend, the characteristics and safety outcomes of patients selected for such transfers remain poorly understood. At our institution, a hospitalist triage physician evaluates patients in the AMC emergency department (ED) for [...]

Background: Diagnosis is complex, dynamic, and high risk for harmful errors in the inpatient setting. It is critical to understand daily workflows and the adaptations that create a safe and resilient diagnostic process, though this is challenging using traditional research methods alone. The aim of this ethnographic study is to identify and analyze personal, team, [...]

Background: Rapid response and code blue events are medical situations that have been designated needing urgent or emergent evaluation by healthcare staff. At their best, these events can represent unfortunate and unavoidable decompensations, but often these situations could have been avoided through earlier recognition of symptoms and signs, intervention, and treatment. This can be especially [...]

Background: Non-infectious complications of urinary catheterization, such as difficult placement and iatrogenic trauma, contribute to significant morbidity in hospitalized patients. While infectious risks are well characterized, the risk factors for non-infectious catheter-related trauma, particularly in female patients, remain poorly described. Methods: This retrospective cohort study reviewed hospitalized adult patients who received Urology consultations for challenging [...]

Background: Aspiration events in hospitalized patients can lead to increased morbidity and mortality through unexpected transfers to a higher level of care, acute respiratory compromise (ARC), or in-hospital cardiac arrests (IHCA). (1) Systematic and scoping reviews have shown that dysphagia, advanced dementia, diabetes mellitus, malnutrition, and poor mobility are associated with aspiration pneumonias in frail [...]