Background: Warfarin-associated adverse drug events are dangerous, common, and costly. Anticoagulation safety is a national priority. While multiple tools exist for warfarin management in the outpatient setting, there is a dearth of guidance with regard to inpatient management. This study aims to: 1) describe a health system’s inpatient chronic warfarin quality metrics, defined by International [...]

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: Rapid response system (RRS) was developed in recent decades for the timely identification and treatment of clinically deteriorating patients. Appropriate use of RRS will decrease the incidence of cardiac arrest and mortality. Although efficacy of RRS was reported mostly in an inpatient setting, there were very limited data in an outpatient setting. The aim [...]

Background: According to CDC estimates, Hospital-Acquired Infections (HAI) account for an estimated 1.7 million infections and 99,000 deaths each year. Studies have shown that using alcohol-based or chlorhexidine-based hand hygiene (HH) is associated with decreased rates of HAIs (1, 2). Nudge theory, a concept in behavioral science, uses positive reinforcement and indirect suggestions to achieve [...]

Background: New ACGME Core requirements require active resident engagement in patient safety. Our institution’s most recent AHRQ Culture of Safety survey revealed poor ratings from residents for closed-loop feedback on event reports they had submitted. Since hospitalists are well-positioned to foster improvement in the culture of safety, we developed an interprofessional intervention in response. Purpose: [...]

Background: Diagnostic error in medicine is increasingly recognized as “the next frontier for patient safety”. Current research has explored the etiologies of diagnostic errors in two unique dimensions: as systems-based or cognitive-based causes. One study, however, suggests that roughly half of all errors stem from both domains. Using a focused ethnographic approach, we sought to [...]

Background: Incident reporting systems are widely utilized to detect adverse events and remain central to many hospital patient safety programs. It is well established that non-physicians file the majority of incident reports, but the barriers to physician reporting are not well understood. Therefore the aims of this study are to understand physicians’ perceived barriers to [...]

Background: Peripherally inserted central catheters (PICCs) are routinely placed in hospitalized patients who are receiving long-term IV antibiotics or who have poor venous access. In our hospital, 1 in 12 patients on the Medicine service receives a PICC line at some point during a hospitalization. 35% of all hospital-acquired venous thromboembolisms (VTEs) on the Medicine [...]

Background: Accurate medication reconciliation during transitions of care can decrease medication related adverse drug events. The Joint Commission has prioritized medication reconciliation as one of the national patient safety goals. Effective pharmacist-physician-patient collaboration can improve the medication reconciliation process and thus medication safety for hospitalized patients Purpose: 1. Develop a standardized provider-pharmacist discharge medication reconciliation [...]

Background: Drug induced long QT syndrome is quite common in daily clinical practice but its impact is unknown. Methods: We searched the PubMed and EMBASE databases (until May 2nd, 2017) to identify studies reporting drug induced Long QT syndrome and followed the PRISMA guidelines. The main outcomes measured in these studies were QTc prolongation, Ventricular [...]