Background: Several institutions have implemented a medical procedure service (MPS) to improve timeliness of bedside procedures and standardize performance and training of procedures by internal medicine (IM) residents (1-2). A critical barrier to starting an MPS has been a lack of experienced proceduralists (3). In 2011, our IM residency program created an MPS led by […]

Background: Several institutions have implemented a medical procedure service (MPS) to improve timeliness of bedside procedures and standardize performance and training of procedures by internal medicine (IM) residents (1-2). A critical barrier to starting an MPS has been a lack of experienced proceduralists (3). In 2011, our IM residency program created an MPS led by […]

Background: The American Geriatric Society (AGS) creates a consensus report, the Beers Criteria, of medications that may potentially inappropriate for older persons. The 2019 Beers Criteria consists of medications across many classifications and indications that could have potentially harmful effects on older patients, including contributing delirium, falls, hypotension, and urinary retention. Providing the highest quality […]

Background: Diagnostic and clinical reasoning errors are common and a source of harm to our patients. Improving clinical reasoning skills is challenging due to the absence of feedback. Care transitions have been recognized as an area of vulnerability for hospitalized patients, however, they also represent opportunities for error recognition and improvement as the oncoming clinician […]

Background: Current literature shows that many graduating health-professional students are not adequately trained to identify safety hazards [1]. With early integration of patient safety education in medical student education, we hope to reduce the occurrence of adverse events longitudinally throughout an individual’s medical career. Data demonstrates that patient safety simulations are an effective method to […]

Background: Diagnostic errors (DEs) are common and can lead to preventable harm in hospitalized patients.[1] To address this problem as part of our AHRQ-funded Patient Safety Learning Laboratory, we characterized diagnostic process failures that contribute to DEs.[2,3] Next, we refined three interventions (Figure 1) that addressed common process failures and were embedded into our electronic […]

Background: CMS launched the Hospital Value-Based Purchasing (VBP) Program in 2010 as part of their initiatives to incorporate healthcare quality into Medicare payment structures. Participating hospitals are assessed according to four domains: Clinical Care, Person and Community Engagement, Safety, and Efficiency and Cost Reduction. Interventions to improve patient safety such as hand hygiene, contact precautions, […]

Background: Hospitalized patients may require central venous access devices (CVADs) for inadequate intravenous (IV) access. CVADs have known complications, including peri-procedural trauma and central line associated bloodstream infections (CLABSI). CLABSI is of concern for patients and hospital systems, as it is largely preventable and used as a quality measure. A CVAD alternative is a short […]

Background: Physical restraint use among patients hospitalized with dementia and behavioral disturbances has not been studied on a national level in the United States. We aimed to determine rates of physical restraint use among hospitalized patients with dementia and behavioral disturbances and to characterize associations with mortality and utilization metrics. Methods: National Inpatient Sample database […]

Background: Failure to follow-up on lab tests and radiology results can lead to major patient safety concerns due to missed or delayed diagnoses and can be a cause for litigation for health care practitioners. With increasing patient loads, the volume of follow-up testing and clarifications to documentation needed for billing can be a significant burden […]