Background: Clinicians encounter sudden death among aortic stenosis (AS) patients especially after they become symptomatic. Mortality is 50% at 1 year and 70 to 80% at 2 years without aortic valve replacement. However, there have been few studies that investigate the predictor for short-term sudden cardiac arrest in patients with severe AS. We investigated the [...]

Background: A midsize health system recognized a pattern in Serious Safety Events (SSE) occurring in its hospitals. Half of all SSE-1 (deaths) and SSE-2 (severe permanent harm) were attributed to delays in physician evaluation of patients admitted through the Emergency Department (ED). Purpose: The health system engaged stakeholders in a conversation initiated by an Admission [...]

Background: At its 2014 peak, the opioid overdose crisis claimed nearly 30,000 lives, but many hospitals and health systems have small opioid-related initiatives working in disjointed fashion rather than a cohesive response.  Purpose: We created a hospital-wide initiative called the “Brigham Comprehensive Opioid Response and Education” (B-CORE) program to reduce opioid-related morbidity and mortality in [...]

Background: Inpatient falls are a patient safety concern in all healthcare facilities. There is currently limited data on the utility of head computed tomography (CT) for inpatient falls. The New Orleans Criteria (NOC) is a validated tool used to determine the appropriateness of neuroimaging in the emergency department after sustaining a fall with minor head [...]

Background: Unexpected overnight adverse events are known to correlate with worse outcomes in inpatients.  Unfortunately, the exact occurrence and etiologies of such events have been less known.    Purpose: The aim of our study was to clarify the occurrence, etiologies of unexpected overnight adverse events and also propose the algorithm so that the catastrophic events [...]

Background: Central line-associated bloodstream infection (CLABSI) is a preventable complication. In the United States, there are more than 20,000 CLABSI per year, resulting in a cost of about $30,000 per infection. A number of interventions have been employed to decrease the risk of CLABSI. Previous studies have documented the importance of simulation-based training. There is [...]

Background: As of December 2015, 49 states initiated the CMS mandated legislation on “Prescription Drug Monitoring Programs.” Yet opiates continue to be commonly prescribed in older adults, despite their well-known risks. This study aims to determine patterns of opiate prescribing, specifically in hospitalized older adults and their impact on outcomes. Methods: This one year retrospective [...]

Background: Intravenous low-molecular weight iron dextran is indicated for patients with iron deficiency who are unable to take oral iron or experience insufficient efficacy with oral replacement. Adverse effects have been reported, including anaphylaxis and death. The primary purpose of this study was to determine the proportion of patients experiencing adverse reactions in a wide [...]

Background: Hospital associated injury is the third leading cause of death in the United States. Lack of communication about patient safety issues among care team members and with patients is a key source of hospital errors and patient harm, and making errors more visible is a key strategy to reduce negative outcomes. Electronic health record [...]

Background: Determining the quality of medication reconciliation (MR) is a laborious and time-intensive process, often involving chart review and detailed patient interviews. Purpose: To identify meaningful, measurable process measures for high-quality MR obtainable from electronic health records (EHR), and to determine if performance on these measures responded to a campaign focused on improving MR. Description: [...]