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 manner. Underlying contributing factors include system flaws (e.g., communication barriers) and cognitive errors (e.g., anchoring), factors that are often overlooked [...]

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 in inappropriate UFH dose adjustments that can negatively impact patient care. In 2015, we deployed an electronic health record (EHR) [...]

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 rates leading to a desire to implement a EWS system. Over a three-year period we reviewed the literature, developed, and [...]

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 especially true for warfarin dosing, which is complicated by a lack of consensus among validated initial dosing nomograms. As part [...]

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 is a missed opportunity, as housestaff spend a significant amount of their time in direct patient care and can see [...]

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 diagnostic error in early readmissions, but this may be an insensitive method. Past studies of diagnostic error in primary care [...]

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, delays in care during the transition from the ED to an inpatient level of care could result in potentially avoidable [...]

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 no interventions have been proven to decrease unnecessary urinary catheter use in Japan. Our aim of this study is to [...]

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 reach the patient, they can result in serious harm. The Office of the National Coordinator for Health Information Technology Patient [...]

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 to clinical reasoning. We therefore undertook this study to establish a metric to evaluate hospitalists’ documentation of clinical reasoning in [...]