Session Type
Meeting
Search Results for Patient Safety
Abstract Number: 210
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Diagnostic error in acute care represents an unresolved safety issue: error rates range from 4.8 to 49.8%. If the diagnosis is delayed or incorrect, the patient may not get correct treatment in a timely manner. Underlying contributing factors include system flaws (e.g., communication barriers) and cognitive errors (e.g., anchoring), factors that are often overlooked […]
Abstract Number: 212
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Numerous early warning systems (EWS) exist as potential tools to improve patient safety. Our system recognized higher than peer rates of rapid response (RRT) utilization as well as higher than desired out-of-ICU code blue rates leading to a desire to implement a EWS system. Over a three-year period we reviewed the literature, developed, and […]
Abstract Number: 214
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Voluntary incident reporting systems are an essential component of a high reliability organization (HRO). Historically, housestaff contribute just 1% of all patient safety intelligence (PSI) events reported at our tertiary care academic institution. This is a missed opportunity, as housestaff spend a significant amount of their time in direct patient care and can see […]
Abstract Number: 215
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days). A single prior study of early readmissions applied a binary (yes/no) metric to assess for diagnostic error in early readmissions, but this may be an insensitive method. Past studies of diagnostic error in primary care […]
Abstract Number: 216
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: The first 24 hours of a patient’s hospitalization is a vulnerable time period, with many aspects of care occurring at a time when patients are at their highest levels of medical acuity. Compounding this, delays in care during the transition from the ED to an inpatient level of care could result in potentially avoidable […]
Abstract Number: 217
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Catheter-associated urinary tract infection (CAUTI) is a common and clinically important hospital-associated infection throughout the world. A few data from Japan exist regarding the prevalence and appropriateness of urinary catheters in hospitalized patients but no interventions have been proven to decrease unnecessary urinary catheter use in Japan. Our aim of this study is to […]
Abstract Number: 218
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: The electronic health record (EHR) and health care provider workflow process may contribute to patient misidentification or wrong-patient errors. When self-caught by the provider, these errors are classified as near-miss errors. When these errors reach the patient, they can result in serious harm. The Office of the National Coordinator for Health Information Technology Patient […]
Abstract Number: 222
Hospital Medicine 2019, March 24-27, National Harbor, Md.
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, […]
Abstract Number: 224
Hospital Medicine 2019, March 24-27, National Harbor, Md.
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 […]
Abstract Number: 226
Hospital Medicine 2019, March 24-27, National Harbor, Md.
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 […]