Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Residents, because they are on the frontlines of the provision of care, are integral to improving care. Yet the Accreditation Council for Graduate Medical Education (ACGME) has reported residents are not as engaged in improving patient safety as they could be, noting, “Though most residents and fellows were aware of their [clinical learning environment]’s [...]

Background: Diagnostic and clinical reasoning errors are common and a source of harm to our patients. Improving clinical reasoning skills is challenging due to the absence of feedback. Care transitions have been recognized as an area of vulnerability for hospitalized patients, however, they also represent opportunities for error recognition and improvement as the oncoming clinician [...]

Background: Since 1951, medical television dramas have impacted how the public views, understands, and learns about the medical profession. Previous studies have examined how these shows depict topics such as cardiopulmonary resuscitation; other studies have shown that medical television dramas influence viewers’ perceptions of the healthcare profession. Our particular area of interest is that of [...]

Background: Since the publication of the Institute of Medicine report To Err Is Human in 1999, preventable inpatient deaths in the United States have been estimated as between 44,000 and 98,000 deaths annually. A more recent review concluded that the number of preventable deaths was over 250,000 cases annually. Critics have pointed out that these [...]

Background: A problem list serves as a central place for hospital-based clinicians to obtain a comprehensive and concise view of the patient’s active medical conditions. Use of the hospital problem list has many potential benefits: it provides a mental model of patient’s health status; streamlines the documentation process; makes chart review more efficient; facilitates communication [...]

Background: Accurate and reliable medication reconciliation (MedRec) is an indispensable step ensuring patient safety and minimizing medical errors during transitions of care. Yet, it is one of the most challenging aspects in healthcare quality and safety. In fact, inaccurate MedRec accounts for 40 % of medication errors, up to 20% of which result in harm [...]