Background: TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) has been shown to improve patient safety by improving teamwork and communication skills amongst all members of the interdisciplinary team. Methods: We developed a 4-hour TeamSTEPPS multi-disciplinary training session, conducted in our simulation center. We invited 90 core members of the medicine service to [...]

Background: We observed that clinical pages in our institution on both medical and surgical services do not always reach the primary inpatient provider. Because we use pagers to communicate critical, time-sensitive information, delayed or misdirected communication can adversely impact patient care. Purpose: Our goal was to quantify the frequency with which pages did not reach [...]

Background:  While many institutions train housestaff to mitigate hospital hazards, few have exploited the crucial concept of situational awareness (i.e. mindfulness of the patient environment) to teach patient safety. One method to promote situational awareness is through the embedding of safety and low-value care hazards into simulation-based training exercises. Purpose: To assess incoming interns’ ability [...]

Background: Clinicians rely on physiologic monitor alarms to notify them of their patients’ changing vital signs. Currently, alarms occur very frequently and usually do not warrant clinical intervention. High alarm burden can lead to alarm fatigue, often observed as a slower response or unintentional ignoring of clinically important alarms. For this reason, alarm fatigue has [...]

Background: Venous thromboembolism (VTE), both pulmonary embolism (PE) and deep vein thrombosis (DVT), causes morbidity and mortality in hospitalized patients. The duration of VTE risk in trauma, particularly after discharge, is not well understood, especially in the context of shortened hospital stays. Although guidelines provide recommendations for extended VTE prophylaxis after major orthopedic surgery, such [...]

Background: Critical lab values are those results that require rapid notification to clinical staff so that urgent interventions can be made to avoid morbidity or mortality. The Joint Commission requires that hospitals have an effective critical lab value process in place.  The process is a time-consuming multi-step progression of phone calls with associated documentation.  The [...]

Background: Previous studies examining continuous patient monitoring in the ICU and emergency department suggest that substantial telemetry alarm burden combined with a high proportion of false positive alerts may jeopardize patient outcomes. Currently, little is known about the burden and value of specific alarms on the general wards. Methods: As part of a quality improvement [...]

Background: Day-to-night inpatient handoff is a high-risk moment, with potential for miscommunication. A novel handoff program recently reduced medical errors and preventable adverse events. Historically, handoffs performed by Internal Medicine residents at our institution were not standardized and there was little workplace-based performance feedback. We evaluated the impact of a novel standardized handoff tool and [...]

Background: The United States is responsible for 43% of lab expenditures worldwide, and up to 30% of lab tests may be unnecessary.  Purpose: This project aims to determine if a human “best practice alert (BPA)” could decrease the number of unnecessary labs ordered by residents at a major academic medical center.  Description: Three internal medicine [...]