Background: Many hospitalized patients have difficulty understanding what their care team tells them about medications and how to comply with medications. Communication failures about medications can have devastating consequences for hospitalized patients. Patients who report good physician communication, clear directions about how to take their medications, and more medication information are more compliant with their [...]

Background: Our institution is a Level 1 regional trauma center with a large inpatient volume. A large percentage of these patients are elderly, with the traumatic events occurring as sequelae of their age, debility or medical complications. Last year, we developed a Trauma/Acute Care Surgery Hospitalist Co-Management program, due to, in large part, the increasing [...]

Background: Quality improvement (QI) has been recognized as a core component of medical resident training and progressive engagement with QI is required by the American Council of Graduate Medical Education’s Clinical Learning Environment Review. Prior to 2015, no formal QI education was provided within our internal medicine residency program. This deficiency prompted residency program leadership [...]

Background: Interdisciplinary communication, quality improvment, and patient safety, are integral components to providing quality healthcare. Furthermore, the ACGME recognizes the importance of the learning and working environment, a culture of safety, and providing opportunities for learners to participate in interprofessional quality improvement activities which it designates as a core program requirement. At the University of [...]

Background: Implementing technology with the goal of eliminating preventable hospital-acquired conditions (e.g., CAUTI, CLABSI, etc.) in the acute care setting is an ongoing challenge, but it is crucial to creating a safer healthcare system. Increasingly, organizations are collaborating with systems engineering, human factors, and data analytic experts to ensure successful design, development, and implementation of [...]

Background: Advances in technology and life-sustaining interventions afford patients access to a wider network of subspecialized care through inter-facility transfers. Implicit in these transfers are multiple complex steps that leave patients vulnerable to adverse events. The few guidelines that exist regarding the inter-facility transfer process focus on critically-ill or surgical patients, and emphasize pre-transfer communication [...]

Background: Inconsistent transitions of care from the inpatient to outpatient setting may lead to preventable readmissions. Critical processes completed at discharge shown to reduce readmissions at our institution include admission and discharge medication reconciliation, clinically appropriate follow-up scheduled prior to discharge, and timely completion of a discharge summary within 48 hours of discharge (the “Core [...]

Background: Baystate Children’s Hospital serves a population that is vulnerable to unsafe sleep practices. By July 2017, there were 6 cases of accidental infant deaths in Hampden County MA, attributed to unsafe sleeping practices, primarily due to co-sleeping. In Springfield, MA, infant mortality rate (9.2%) is double that of the state rate (4.4%). Rates of [...]

Background: The University of Colorado Hospital (UCH) fails to meet the National Healthcare Safety Network (NHSN) benchmarks for central line utilization rates and central line-associated bloodstream infections (CLABSI). Peripherally inserted central catheters (PICCs) are central lines that are overused and misused at UCH. Overuse of PICC lines increases the risks of CLABSI and PICC-associated deep [...]

Background: Obtaining blood work through venipuncture is an important part of the diagnosis and management of hospitalized patients. Through formal and informal patient complaints, we found that patients admitted to the University of Colorado Hospital (UCH) report an excessive number of venipunctures for laboratory blood sampling. This results in overuse of resources, excess patient discomfort, [...]