Background: Accurate, timely admission medication reconciliation (AMR) is a key patient-safety driver. Clinician-performed AMR has higher error rates compared to pharmacy-performed AMR. At our large, tertiary care institution, pharmacists capture only 75% of AMRs and require up to 48h for completion. Delays and errors in clinician-performed AMR on medicine floors have led to patient safety [...]

Background: Diagnostic error is a major threat to the safety of hospitalized patients, affecting as many as 1 in 4 patients and leading to 7% of inpatient deaths. However, diagnostic error remains difficult to identify and measure, particularly in the hospital setting, where determination of an error relies on medical record review. Measurement difficulty also [...]

Background: Medical errors are the third leading cause of death in the United States yet physicians report minimal education on how to disclose errors and adverse events. To Err is Human shed light on the severity of errors. As a result, communication and resolution programs were developed over the past two decades to attempt to [...]

Background: Mortality risk assessment is crucial for predicting patient outcomes, assessing patient care delivery, and improving healthcare quality. Although high-quality medical documentation is critical for mortality risk assessment tools, provider documentation may be inconsistent, relies on coding teams for support, and may not directly reflect provider orders. Complete and precise documentation and coding can improve [...]

Background: The under-reporting of adverse events has been a significant issue in patient and healthcare staff safety, and prevents improvement of individual and systemic errors in healthcare. As champions for quality and safety in their institutions, it is essential hospitalists who work with housestaff  serve as role models to encourage trainees to report safety issues. [...]

Background: Tracheostomies are commonly performed on critically ill patients requiring prolonged respiratory support. Managing them in intermediate care units (IMCU) presents challenges, as complications such as tube displacement, infection, and airway obstruction can pose significant risks. Structured safety protocols like checklists have been successfully used in other high-risk healthcare settings to mitigate these risks. Thomassen [...]

Case Presentation: A 43 year-old man presented with one day of diffuse joint pains and fevers. He had new onset severe joint pains and stiffness of the neck, shoulders, elbows, wrists, fingers, hips, knees, and ankles. He used a continuous subcutaneous insulin infusion device to manage type 1 diabetes. He recently had a small bowel [...]