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Abstract Number: 352
SHM Converge 2023
Background: Documentation shortcut tools in electronic health records, such as dot phrases, are essential in a busy clinical environment to promote efficiency and standardize care, but are known to carry risks. The extent to and mechanism by which dot phrase errors occur are poorly characterized. In addition, there are no defined interventions for hospitalists to […]
Abstract Number: 361
Hospital Medicine 2016, March 6-9, San Diego, Calif.
Background: Medical overuse, defined as the provision of services for which harms outweigh benefits, is increasingly recognized as a driver of high cost and poor clinical outcomes in the U.S. health care system. Despite increasing attention to overuse, methods for reducing it are unclear. In contrast, methods of identification, analysis, and prevention of medical errors […]
Abstract Number: 372
SHM Converge 2024
Background: To address the risk of missed or delayed diagnoses, organizations need to identify and learn from their diagnostic opportunities. However, current approaches to identifying diagnostic opportunities are insensitive, resource intensive and often have low yield.(1,2) Evaluation of diagnostic trajectories can highlight diagnostic opportunities. For example, a patient may re-present to the healthcare system with […]
Abstract Number: 375
Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.
Case Presentation: A 65-year-old female, Spanish speaking, Jehovah’s Witness, with a past medical history of insulin-dependent diabetes, PUD 2/2 H pylori treated but not tested for cure, and osteoarthritis who presents with hematemesis of one-day duration and abdominal pain of 5 days duration.The patient woke up vomiting blood on the morning of admission. While the […]
Abstract Number: 378
SHM Converge 2023
Background: Morbidity and Mortality (M&M) conferences are ubiquitous among internal medicine (IM) residency programs, but often fail to improve patient safety and foster learning.1,2 One key determinant of a successful M&M conference is the choice of patient safety event (i.e. M&M case) that is analyzed or presented. However, the characteristics of an effective M&M case […]
Abstract Number: 381
SHM Converge 2023
Background: Lost or improperly labeled specimens may be medically detrimental to patients and have legal implications for the medical professionals and healthcare facility involved. Endoscopy is an especially high-risk location for specimen errors given the large number of biopsies obtained and the high volume of patients served daily by the same team. A 61-year-old male […]
Abstract Number: 402
Hospital Medicine 2019, March 24-27, National Harbor, Md.
Background: Medication discrepancies are prevalent at various transitions of care including hospital discharge. Medication changes at hospital discharge may be misunderstood by the patient or not conveyed throughout the healthcare system. Most outpatient pharmacy medication records were created for the sole purpose of dispensing prescriptions. Pharmacists have little incentive to remove outdated medications and are […]
Abstract Number: 458
Hospital Medicine 2020, Virtual Competition
Background: Medically complex patients discharged from hospitals to skilled nursing facilities (SNFs) are at high risk for unintentional errors, re-hospitalization, and mortality. Commonly reported transitional care errors include poor communication of critical information, limited access to medical records, and lack of clarity as to follow-up plans or patients care goals. Telehealth is increasingly used in […]
Abstract Number: 497
Hospital Medicine 2018; April 8-11; Orlando, Fla.
Case Presentation: A 28-year-old woman with sickle cell disease and chronic pain who required inpatient care several times yearly presented with worsening nausea, emesis and uncontrolled pain to the emergency department (ED). Symptoms were typical of prior pain crises. The patient followed regularly with a hematologist undergoing monthly red blood cell exchange transfusions. In the […]
Abstract Number: 557
Hospital Medicine 2016, March 6-9, San Diego, Calif.
Case Presentation: A 65 year-old man with end-stage renal disease was brought to the Emergency Department (ED) when he developed confusion and shortness of breath at a skilled nursing facility (SNF). He had a recent prolonged hospitalization for pelvic osteomyelitis and was discharged to the SNF 3 days before presentation. In the ED, the providers […]