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 patients with diabetes grows, so does the potential for adverse events during hospitalization. Previous studies have shown that both hyper- [...]

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, and loss of confidence, with little support from their institutions. Second Victim Programs (SVPs) were introduced to improve support for [...]

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, including their causes and evidence to-date on how to intervene to reduce the harm associated with them. In this report, [...]

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 a change in clinical status. Patients with End-Stage Renal Disease (ESRD) fare worse than age-, gender-, and race-matched populations. We [...]

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 harm to themselves or hospital staff. Our BRT is a multidisciplinary group consisting of a psychiatric nurse supervisor, medical nurse [...]

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 mortality benefit by combining chemical and mechanical prophylaxis. Inappropriate prophylaxis places patients at risk for adverse events like bleeding, risk [...]

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 Electronic Health Records (EHRs) to reduce wrong-patient errors; however, only a small proportion of hospitals nationally utilize patient photographs. A [...]

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 recent review concluded that the number of preventable deaths was over 250,000 cases annually. Critics have pointed out that these [...]

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 analysis evaluated the safety profile of rifaximin alone vs rifaximin + lactulose (combination) in patients with cirrhosis. Methods: In a [...]

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 discharged with one or more TPAD. Recent studies show that 30-40% of resulted TPAD warrant a change in patient management. [...]