Background: In the past 20 years, the “10/30” rule for blood transfusions has been replaced with conservative guidelines which have demonstrated improved patient outcomes and reduced overall healthcare costs. Hospitals across the country have enlisted transfusion subcommittees to review the appropriateness of blood transfusions. Within medical training, resident physicians rotate with different attendings who have [...]

Background: Critical lab values are those results that require rapid notification to clinical staff so that urgent interventions can be made to avoid morbidity or mortality. The Joint Commission requires that hospitals have an effective critical lab value process in place.  The process is a time-consuming multi-step progression of phone calls with associated documentation.  The [...]

Background: Patients are discharged home on medications different than those they were taking before admission.  New and discontinued medications as well as dosage changes contribute to medication-related adverse events.  Purpose: To help address this problem, interns in our program developed a standard process during their quality improvement (QI) curriculum to ensure that at least 95% [...]

Background: Communication breakdown plays a part in the majority of adverse events in healthcare. Physician to physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematized according to a standardized bundle. However,  the degree to which individual elements of this bundle, including written versus verbal handoffs, contribute [...]

Background: Morbidity and Mortality Conference (MMC) has been recognized as a valuable educational resource in training programs to improve patient safety. Traditional MMCs are often poorly defined in terms of format, goals, and outcomes, leading to ineffective reflection, discussion and action. Increasing evidence suggests that a structured and transparent approach to MMCs results in measurable [...]

Background: Rapid response teams (RRT) are critical to the timely and appropriate management of acutely decompensating patients within many hospital systems. In the academic setting, the vital role of RRT leader is often filled by a resident physician who may lack the necessary medical knowledge and experience to initiate timely management for these patients. 100% [...]

Background: Appropriate and timely documentation of rapid response events has been shown to have a significant impact on patient care and outcomes. Prior to January 2021, our institution did not have a standardized rapid response note template to facilitate best clinical documentation practices. A review of rapid response events at our institution that occurred during [...]