Session Type
Meeting
Search Results for Safety
Abstract Number: 207
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Mortality review, well-documented in the medical literature, is a standardized process used to identify patient safety improvement opportunities and also to evaluate providers. As patient safety experts, hospitalists often review mortality cases for their hospitalist group or hospital. As the volume of cases is often not trivial, it can be difficult to allocate the […]
Abstract Number: 209
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Midline vascular catheters are gaining popularity in clinical practice. However, patterns of use and outcomes related to these devices are not well known. Methods: Trained abstractors collected detailed patient-, device- and outcome data from medical records of hospitalized patients that received midline catheters from 12 hospitals participating in the Michigan Hospital Medicine Safety (HMS) […]
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: 211
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Hospitalized patients receiving direct oral anticoagulants (DOACs) sometimes require bridging with unfractionated heparin (UFH). Monitoring UFH with anti-Xa assays has been shown to correlate with better outcomes. However, DOACs interfere with anti-Xa assays resulting in inappropriate UFH dose adjustments that can negatively impact patient care. In 2015, we deployed an electronic health record (EHR) […]
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: 213
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Anticoagulants are among the highest-risk medications in hospitalized patients. Studies have demonstrated that a majority of in-hospital anticoagulant adverse drug events are not only preventable, but are the result of excessive dosing. This is especially true for warfarin dosing, which is complicated by a lack of consensus among validated initial dosing nomograms. As part […]
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 […]