Background: General wards are high-risk clinical areas, but frontline staff face operational challenges not prioritized in national safety initiatives. Team reporting may identify important risks to patient care, although its impact as a safety strategy is unknown. We developed HEADS-UP (Hospital Event Analysis Describing Significant Unanticipated Problems), a system for prospective clinical team surveillance (PCTS). [...]

Background: Diagnostic errors (DE), defined as missed opportunities to make a correct or timely diagnosis based on the available evidence, are a critical but understudied cause of patient harm. While previous efforts have focused on examining the incidence and factors contributing to DEs in ambulatory and emergency room settings, fewer studies have examined incidence of [...]

Background: Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of single interventions. We sought to implement a set of complementary interventions and evaluate the effect on interprofessional teamwork and patient safety. Methods: The REdesigning SystEms to Improve Teamwork and [...]

Background: General wards are high-risk clinical areas, but frontline staff face operational challenges not prioritized in national safety initiatives. Team reporting may identify important risks to patient care, although its impact as a safety strategy is unknown. We developed HEADS-UP (Hospital Event Analysis Describing Significant Unanticipated Problems), a system for prospective clinical team surveillance (PCTS). [...]

Background: Most academic general medical services cover patients across several different care units in the hospital. Studies have shown that de-regionalized care leads to a lack of team cohesion and poor communication between healthcare providers. Prior studies have shown that teamwork improves patient outcomes and increases health care worker satisfaction. However, little information using validated [...]

Background: Geographic localization of inpatient physician services to nursing units has been suggested to improve teamwork and patient safety among health care professionals, while perceived lack of collaboration has been associated with worse patient outcomes. On our inpatient oncology units, we previously found that large discrepancies exist in perceptions of teamwork and collaboration among professionals, [...]

Background:  The Society of Hospital Medicine considers stroke care a core competency in hospital medicine.  It also challenges hospitalists to lead, coordinate, and participate in multidisciplinary efforts to improve stroke care within their organizations.  Hospitalist trainees will be better positioned to accomplish this if they have a broad exposure to the continuum of stroke care [...]

Background: Medical errors in hospitals are a significant threat to patient safety and often result from poor communication or poorly-activated interprofessional teams. Despite a recent focus on interprofessional education (IPE) in pre-clinical years and simulation settings, formal curricula for teaching medical trainees interprofessional communication and teamwork skills in clinical settings are lacking. Purpose: To create [...]

Background: Hospital readmissions continue to remain prevalent despite their negative impact on patient outcomes and economic cost. One in five Medicare beneficiaries is expected to be readmitted within 30 days. As a result, strategies to reduce readmissions is a point of emphasis for all healthcare systems. Guidance regarding reducing readmissions differs and is not abundant. [...]

Background: Joint Commission has identified “communication” as the third most frequent root cause of sentinel events.1 Alpha-numeric pagers are common for communication among healthcare professionals. Pagers are not HIPAA compliant and communication through pagers often lacks sufficient information for effective communication.2 Because pager communication is one-way, closed loop communication requires a return telephone call, disrupting [...]