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Thirnbeck CK, Espinoza ED, Beaman EA, Rozen AL, Dukes KC, Singh H, Herwaldt LA, Landrigan CP, Reisinger HS, Cifra CL. Interfacility Referral Communication for PICU Transfer. Pediatr Crit Care Med 2024; 25:499-511. [PMID: 38483193 PMCID: PMC11153023 DOI: 10.1097/pcc.0000000000003479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVES For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs. DESIGN Mixed methods retrospective study of audio-recorded referral calls between referring clinicians and receiving PICU physicians for urgent interfacility PICU transfers. SETTING Academic tertiary referral PICU. PATIENTS Children 0-18 years old admitted to a single PICU following interfacility transfer over a 4-month period (October 2019 to January 2020). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We reviewed interfacility referral phone calls for 49 patients. Referral calls between clinicians lasted a median of 9.7 minutes (interquartile range, 6.8-14.5 min). Most referring clinicians provided information on history (96%), physical examination (94%), test results (94%), and interventions (98%). Fewer clinicians provided assessments of illness severity (87%) or code status (19%). Seventy-seven percent of referring clinicians and 6% of receiving PICU physicians stated the working diagnosis. Only 9% of PICU physicians summarized information received. Interfacility handoffs usually involved: 1) indirect references to illness severity and diagnosis rather than explicit discussions, 2) justifications for PICU admission, 3) statements communicating and addressing uncertainty, and 4) statements indicating the referring hospital's reliance on PICU resources. Interfacility referral communication was similar to intrahospital shift-to-shift handoffs with some key differences: 1) use of contextual information for appropriate PICU triage, 2) difference in expertise between communicating clinicians, and 3) reliance of referring clinicians and PICU physicians on each other for accurate information and medical/transport guidance. CONCLUSIONS Interfacility PICU referral communication shared characteristics with intrahospital shift-to-shift handoffs; however, communication did not adhere to known elements of high-quality handovers. Structured tools specific to PICU interfacility referral communication must be developed and investigated for effectiveness in improving communication and patient outcomes.
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Affiliation(s)
- Caitlin K. Thirnbeck
- Division of Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth D. Espinoza
- Oregon Health and Science University School of Nursing and School of Medicine, Portland, Oregon
| | | | - Alexis L. Rozen
- University of Iowa College of Public Health, Iowa City, Iowa
| | - Kimberly C. Dukes
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
| | - Christina L. Cifra
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Tjan TE, Wong LY, Rixon A. Conflict in emergency medicine: A systematic review. Acad Emerg Med 2024; 31:538-546. [PMID: 38415363 DOI: 10.1111/acem.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research. METHODS Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles. RESULTS Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships. CONCLUSIONS In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.
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Affiliation(s)
- Timothy Edward Tjan
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
- School of Business, Law and Entrepreneurship, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Andrew Rixon
- Department of Business, Strategy and Innovation, Griffith Business School, Griffith University, Brisbane, Queensland, Australia
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3
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Leeper WR, James N. Trauma Bay Evaluation and Resuscitative Decision-Making. Surg Clin North Am 2024; 104:293-309. [PMID: 38453303 DOI: 10.1016/j.suc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.
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Affiliation(s)
- William Robert Leeper
- Department of Surgery, Western University, Victoria Campus, London Health Sciences Center, Room E2-215, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas James
- London Health Sciences Center, Victoria Campus, Room E2-214, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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4
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Braam A, Buljac-Samardzic M, Hilders CGJM, van Wijngaarden JDH. Collaboration Between Physicians from Different Medical Specialties in Hospital Settings: A Systematic Review. J Multidiscip Healthc 2022; 15:2277-2300. [PMID: 36237842 PMCID: PMC9552793 DOI: 10.2147/jmdh.s376927] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022] Open
Abstract
Health care today is characterized by an increasing number of patients with comorbidities for whom interphysician collaboration seems very important. We reviewed the literature to understand what factors affect interphysician collaboration, determine how interphysician collaboration is measured, and determine its effects. We systematically searched six major databases. Based on 63 articles, we identified five categories that influence interphysician collaboration: personal factors, professional factors, preconditions and tools, organizational elements, and contextual characteristics. We identified a diverse set of mostly unvalidated tools for measuring interphysician collaboration that focus on information being transferred and understood, frequency of interaction and tone of the relationship, and value judgements about quality or satisfaction. We found that interphysician collaboration increased clinical outcomes as well as patient and staff satisfaction, while error rates and length of stay were reduced. The results should, however, be interpreted with caution, as most of the studies provide a low level of evidence.
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Affiliation(s)
- Anoek Braam
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands,Correspondence: Anoek Braam, Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle Building, P.O. Box 1738, Rotterdam, DR 3000, the Netherlands, Email
| | - Martina Buljac-Samardzic
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Carina G J M Hilders
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jeroen D H van Wijngaarden
- Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
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5
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Zhang W, Wong LY, Liu J, Sarkar S. MONitoring Knockbacks in EmergencY (MONKEY) – An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:481-490. [PMID: 36081749 PMCID: PMC9448349 DOI: 10.2147/oaem.s376419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected – which study investigators termed a “knockback”. Purpose To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks. Selection and Methodology Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan–Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed. Results A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians’ perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty. Conclusion In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.
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Affiliation(s)
- Wendell Zhang
- University of Melbourne Clinical School, Austin Health, Heidelberg, VIC, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
- Correspondence: Lee Yung Wong, Austin Hospital Emergency Department, 145 Studley Road, Heidelberg, 3084, VIC, Australia, Tel +613 9496 5000, Fax +613 9496 3572, Email
| | - Jasmine Liu
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
| | - Soham Sarkar
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
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6
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Kanjee Z, Beltran CP, Smith CC, Lewis J, Hall MM, Tibbles CD, Sullivan AM. "Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center. West J Emerg Med 2021; 22:1227-1239. [PMID: 34787545 PMCID: PMC8597691 DOI: 10.5811/westjem.2021.7.52762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Christine P Beltran
- Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
| | - C Christopher Smith
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Internal Medicine Residency Program, Boston, Massachusetts
| | - Jason Lewis
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Matthew M Hall
- Providence Regional Medical Center, Department of Emergency Medicine, Everett, Washington.,Washington State University, Pullman, Washington
| | - Carrie D Tibbles
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Emergency Medicine Residency Program, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Office of Graduate Medical Education, Boston, Massachusetts
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
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7
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Chladek MS, Doughty C, Patel B, Alade K, Rus M, Shook J, LIttle-Weinert K. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual 2021; 10:e001254. [PMID: 34244172 PMCID: PMC8273485 DOI: 10.1136/bmjoq-2020-001254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the American College of Emergency Physicians and American Academy of Pediatrics recommendations for standardised handoffs in the emergency department (ED), few EDs have an established tool. Our aim was to improve the quality of handoffs in the ED by establishing compliance with the I-PASS handoff tool. METHODS This is a quality improvement (QI) initiative to standardise handoffs in a large academic paediatric ED. Following review of the literature and focus groups with key stakeholders, I-PASS was selected and modified to fit departmental needs. Implementation throughPlan-Do-Study-Act cycles included the development of educational materials, reminders and real-time feedback. Required use of I-PASS during designated team sign-out began in June 2016. Compliance with the handoff tool and handoff deficiencies was measured through observations by faculty trained in I-PASS. As a balancing measure, time to complete handoff was monitored and compared with preintervention data. RESULTS Compliance with I-PASS reached 80% within 6 months, 100% within 7 months and sustained at 100% during the remainder of the study period. The average percent of omissions of crucial information per handoff declined to 8.3%, which was a 53% decrease. Average percentage of tangential information and miscommunications per handoff did not show a decline. The average handoff took 20 min, which did not differ from the preintervention time. Survey results demonstrated a perceived improvement in patient safety through closed-loop communication, clear action lists and contingency planning and proper patient acuity identification. CONCLUSIONS I-PASS is applicable in the ED and can be successfully implemented through QI methodology contributing to an overall culture of safety.
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Affiliation(s)
| | - Cara Doughty
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Binita Patel
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kyetta Alade
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Marideth Rus
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joan Shook
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kim LIttle-Weinert
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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8
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Fekieta R, Rosenberg A, Jenq GY, Emerson BL. A New Tool to Assess Clinician Experience With Patient Care Transitions. Qual Manag Health Care 2021; 30:87-96. [PMID: 33783422 DOI: 10.1097/qmh.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Clinician experience of intrahospital patient care transfers can drive transfer success and safe patient care. Measuring clinician experience can provide insights into opportunities to improve transfer processes that impact patient care. As part of a quality improvement project, we developed a brief survey to gauge clinician experience with patient care transfers that occur within a hospital. METHODS The survey framework was built upon a previously identified taxonomy of intrahospital transfers that includes categories of transfer activities: disposition, notification, preparation, communication, and coordination. The survey tool was administered twice to physicians, nurses, and other health professionals across a single hospital. Data were analyzed comparing providers sending patients, and those receiving patients. RESULTS The survey response rate was 33% to 34% across both years. While helpful in demonstrating improving trends in provider experience and engagement with transfer processes, the survey also allowed for differences between the experiences of sending and receiving providers to be revealed. Nurses reported improved preparedness to receive patients and receivers overall reported improved teamwork. Senders' perceptions showed improved trends in all transfer categories. Preliminary data also suggest acceptable reliability across respondent type, item category, and time. Specifically, reliability across sending and receiving clinicians was demonstrated in the categories of timeliness (α = 0.85) and culture (α = 0.72). Responses of sending clinicians were internally consistent within culture (α = 0.82), while responses of receiving clinicians were internally consistent within culture (α = 0.86), timeliness (α = 0.76), notification (α = 0.77), communication (α = 0.73), and teamwork (α = 0.73). CONCLUSIONS Overall, the survey was feasible to implement and built to optimize content, construct, and response process validity. Survey results drove practical improvement work, such as informing a verbal transfer protocol to improve nursing preparedness to receive patients on general medicine units. As a practical tool, the survey and its results can help hospital administrators to focus on categories of transfer activities that are most problematic for clinicians and to track trends for quality improvement.
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Affiliation(s)
- Renee Fekieta
- Yale University School of Medicine, New Haven, Connecticut (Drs Fekieta and Emerson); Yale University School of Public Health, New Haven, Connecticut (Ms Rosenberg); and University of Michigan Medicine, Ann Arbor (Dr Jenq)
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Tasi MC, Baymon DE, Temin ES, Zheng H, Lehman KM, Baccari B, Tubridy A, Conly B, Yun BJ. Evaluation of Process Improvement Interventions on Handoff Times between the Emergency Department and Observation Unit. J Emerg Med 2020; 60:237-244. [PMID: 33223270 DOI: 10.1016/j.jemermed.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/28/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Mitigating hospital crowding requires judicious use of inpatient resources, making Emergency Department Observation Units (EDOUs) an increasingly vital destination for patients that are not suitable for discharge. Maximizing the utility of the EDOU hinges on efficient patient transfers and safe provider communication, which may be accomplished with asynchronous handoff and an emphasis on pull-through operations. OBJECTIVE The purpose of this study was to assess the impact of an electronic, asynchronous handoff replacing verbal handoff on transfer times from the Emergency Department (ED) to the EDOU. METHODS A retrospective observational study was performed with patients transferred to the EDOU throughout several process improvement measures focused on asynchronous handoff. Multivariable linear regression analysis was used to determine the effect that these process improvements had on the time from EDOU bed assignment to patient transfer. RESULTS There were 14,996 EDOU stays during the 20-month period included in the analysis. Time from EDOU bed assignment to patient transfer decreased significantly with all three interventions studied. An auto-page to the clinicians notifying them of a ready bed reduced the mean time to transfer by 10.1 min (p < 0.0001), asynchronous nursing handoff reduced it by 3.57 min (p = 0.0299), and asynchronous clinician handoff reduced it by 14.67 min (p < 0.0001). CONCLUSION Introducing automatic pages regarding bed status and converting the handoff process from a verbal model to an asynchronous, electronic handoff were effective ways to reduce the time from bed assignment to transfer out of the ED for patients being sent to the EDOU.
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Affiliation(s)
- Michael C Tasi
- Harvard Affiliated Emergency Medicine Residency Program, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Da'Marcus E Baymon
- Harvard Affiliated Emergency Medicine Residency Program, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Elizabeth S Temin
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Hui Zheng
- Massachusetts General Hospital, Boston, Massachusetts
| | - Kendra M Lehman
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Brian Baccari
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aileen Tubridy
- Nursing and Patient Care Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Bridget Conly
- Nursing and Patient Care Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Brian J Yun
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Fekieta R, Rosenberg A, Hodshon B, Feder S, Chaudhry SI, Emerson BL. Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement. Health Syst (Basingstoke) 2020; 10:239-248. [PMID: 34745587 DOI: 10.1080/20476965.2020.1768807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
During intra-hospital transfers, multiple clinicians perform coordinated tasks that leave patients vulnerable to undesirable outcomes. Communication has been established as a challenge to care transitions, but less is known about the organisational complexities within which transfers take place. We performed a qualitative assessment that included various professions to capture a multi-faceted understanding of intra-hospital transfers. Ethnographic observations and semi-structured interviews were conducted with clinicians and staff from the Medical Intensive Care Unit, Emergency Department, and general medicine units at a large, urban, academic, tertiary medical centre. Results highlight the organisational factors that stakeholders view as important for successful transfers: the development, dissemination, and application of protocols; robustness of technology; degree of teamwork; hospital capacity; and the ways in which competing hospital priorities are managed. These factors broaden our understanding of the organisational context of intra-hospital transfers and informed the development of a practical guide that can be used prior to embarking on quality improvement efforts around transitions of care.
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Affiliation(s)
- Renee Fekieta
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | | | - Beth Hodshon
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Beth L Emerson
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
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11
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Zhu W, Patterson BW, Smith M, Rifleman AC, Carayon P, Li J. A Markov Chain Model for Transient Analysis of Handoff Process in Emergency Departments. IEEE Robot Autom Lett 2020; 5:4360-4367. [PMID: 32695881 DOI: 10.1109/lra.2020.2996066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transfer of care between multiple units or facilities is of significant importance for patient safety, care quality, and operation efficiency. Such transfers are often referred to as handoffs in hospitals, which need to be carried out timely, safely, and smoothly with accurate information. This paper introduces a Markov chain model to study the transients of handoff process in hospital emergency departments. The handoff process is modeled by a stochastic process with unavailability of service, which characterizes the constraints in bed capacity, staff shortage, and coordination issues, etc. For systems only allowing one transfer request waiting, the transient performance is obtained through Laplace transform and its inverse transform. Such a result is then used as a building block to study the systems allowing multiple requests waiting through an iteration process, which can reduce the computation complexity substantially. Numerical studies show that such a method can provide estimates of transient performance in the handoff process with acceptable accuracy.
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Affiliation(s)
- Wenjun Zhu
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI 53706, USA
| | - Brian W Patterson
- Department of Medicine, University of Wisconsin, Madison, WI 53705 USA
| | - Maureen Smith
- Departments of Population Health Sciences and Family Medicine & Community Health, University of Wisconsin, Madison, WI 53705 USA
| | - Anne C Rifleman
- University of Wisconsin Hospital and Clinic, Madison, WI 53705 USA
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI 53706, USA
| | - Jingshan Li
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI 53706, USA
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12
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Louie JP, Furnival RA, Roback MG, Jacob AK, Marmet J, Nerheim D, Hendrickson MA. ED RAPID: A Novel Children's Hospital Direct Admission Process Utilizing the Emergency Department. Pediatr Qual Saf 2020; 5:e268. [PMID: 32426634 PMCID: PMC7190248 DOI: 10.1097/pq9.0000000000000268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 02/04/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Direct hospital admission of children without evaluation in the emergency department (ED) is common, but few guidelines exist to maximize safety by assessing patient stability. This report describes a novel approach to support patient safety. METHODS An interdisciplinary children's hospital team developed a brief ED-based evaluation process called the ED Rapid Assessment of Patients Intended for Inpatient Disposition (ED RAPID). It entails a brief evaluation of vital signs and clinical stability by the ED attending physician and nurse. Children deemed stable are admitted to inpatient wards, whereas those requiring immediate intervention undergo full ED evaluation and disposition. We assessed outcomes for all children evaluated through this process from March 2013 through February 2015. RESULTS During the study period, we identified 715 patients undergoing ED RAPID evaluation. Of these, we directly admitted 691 (96.4%) to the hospital ward after ED RAPID evaluation; median ED treatment time was 4.0 minutes. We transitioned 24 (3.4%) to full ED evaluation, 14 (2.0%) because a ward bed was unavailable, and 10 (1.4%) for clinical reasons identified in the evaluation. We admitted four of the 10 stopped (40% of stops, 0.6% of total) to an intensive care unit, and 6 (60% of stops, 0.8% of total) to the hospital ward after ED care. Eight children (1.1%) admitted to the hospital ward after ED RAPID evaluation required a transfer to an intensive care unit within 12 hours. CONCLUSION The ED RAPID evaluation process for children directly admitted to the hospital was feasible and effective in this setting.
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Affiliation(s)
- Jeffrey P. Louie
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Ronald A. Furnival
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Mark G. Roback
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Abraham K. Jacob
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Jordan Marmet
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Daniel Nerheim
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
| | - Marissa A. Hendrickson
- From the Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minn
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A prospective assessment of adequacy of orthopaedic emergency medicine consultations: The experience at an academic level I trauma center. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kwok ESH, Clapham G, White S, Austin M, Calder LA. Development and implementation of a standardised emergency department intershift handover tool to improve physician communication. BMJ Open Qual 2020; 9:e000780. [PMID: 32019750 PMCID: PMC7011887 DOI: 10.1136/bmjoq-2019-000780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/03/2020] [Accepted: 01/14/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians. AIM Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months. METHODS We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling. MEASURES Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics. RESULTS We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education. CONCLUSIONS We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.
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Affiliation(s)
- Edmund S H Kwok
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Glenda Clapham
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Shannon White
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael Austin
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Abraham J, Burton S, Gordon HS. Moving patients from emergency department to medical intensive care unit: Tracing barriers and root contributors. Int J Med Inform 2019; 133:104012. [PMID: 31726385 DOI: 10.1016/j.ijmedinf.2019.104012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/15/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patient transfers involve the physical movement of patients, along with the transfer of their care-related information, responsibility, and control between sending and receiving clinicians. Patient transfers between critical care units are complex and vulnerable to bottlenecks. OBJECTIVE To examine the patient transfer process from emergency department (ED) to medical intensive care unit (MICU). MATERIALS AND METHOD A qualitative study on transfers from ED to MICU was conducted at two academic hospitals. Using a process-based methodological approach supported by shadowing of patient transfers and clinician interviews, we examined the process-based similarities and differences in barriers and strategies used across hospitals. RESULTS Phases underlying ED-MICU transfer process included: pre-transfer phase involving ED care coordination and MICU transfer decision-making; transfer phase involving ED-MICU resident handoff, and post-transfer phase involving MICU care planning and management. DISCUSSION AND CONCLUSION Transfer of information, responsibility and control between sending and receiving clinicians is key to effective management of interdependencies between the pre-transfer, transfer and post-transfer phases underlying the patient transfer process. Evidence-based strategies to address challenges related to transfer of information, responsibility and control include the use of videophones and communication checklists, the allocation of a crash bed, engagement of sending, receiving and consulting teams in the physical movement of patients, and in-hospital transfer protocols.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St Louis, St. Louis, MO, United States.
| | - Shirley Burton
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois, Chicago, United States
| | - Howard S Gordon
- Jessse Brown VAMC and VA HSR&D Center of Innovation for Complex Chronic Healthcare, Chicago, United States; Department of Medicine, College of Medicine, University of Illinois, Chicago, United States
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Multistate model of the patient flow process in the pediatric emergency department. PLoS One 2019; 14:e0219514. [PMID: 31291345 PMCID: PMC6619791 DOI: 10.1371/journal.pone.0219514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/25/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling. Methods In this study, 75,591 patients admitted to the ED from March 1st, 2016 to February 28th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process. Results Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong. Conclusions The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model.
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Hendrickson MA, Schempf EN, Furnival RA, Marmet J, Lunos SA, Jacob AK. The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication. Jt Comm J Qual Patient Saf 2019; 45:431-439. [PMID: 31000353 PMCID: PMC6588502 DOI: 10.1016/j.jcjq.2019.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 02/01/2019] [Accepted: 02/15/2019] [Indexed: 10/27/2022]
Abstract
Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED. METHODS The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care. RESULTS A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration. CONCLUSION The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.
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Affiliation(s)
- Marissa A. Hendrickson
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Emma N. Schempf
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ronald A. Furnival
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Jordan Marmet
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Scott A. Lunos
- Clinical and Translational Science Institute/Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, United States
| | - Abraham K. Jacob
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
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Wang ES, Velásquez ST, Smith CJ, Matthias TH, Schmit D, Hsu S, Leykum LK. Triaging Inpatient Admissions: an Opportunity for Resident Education. J Gen Intern Med 2019; 34:754-757. [PMID: 30993610 PMCID: PMC6502926 DOI: 10.1007/s11606-019-04882-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.
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Affiliation(s)
- Emily S Wang
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA.
- Division of General and Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Sadie Trammell Velásquez
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of General and Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Christopher J Smith
- Division of Hospital Medicine, University of Nebraska Medicine Center, Omaha, NE, USA
| | - Tabatha H Matthias
- Division of Hospital Medicine, University of Nebraska Medicine Center, Omaha, NE, USA
| | - David Schmit
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of General and Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Sherwin Hsu
- Department of Medicine, Olive View - University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Luci K Leykum
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
- Division of General and Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Baylis J, Miloslavsky EM, Woods R, Chan TM. Conquering Consultations: A Guide to Advances in the Science of Referral-Consultation Interactions for Residency Education. Ann Emerg Med 2019; 74:119-125. [PMID: 30661857 DOI: 10.1016/j.annemergmed.2018.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Indexed: 11/16/2022]
Abstract
Consultations with specialist services occur with regularity in the emergency department (ED). Emergency physician interactions with consultants in the ED offer an amazing opportunity for collegial patient care but can also present a number of challenges. Navigating the consultation process requires effective communication skills that are considered a core competency within the Accreditation Council for Graduate Medical Education, as well as the CanMEDS frameworks of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. Because of time pressure, environmental complexities, patient acuity, and the fast pace of the ED, learning this skill can be challenging for trainees and is something many attending physicians will struggle with at times. It has been established that trustworthiness and familiarity are 2 key components within the referral-consultation process. Both components rely on reputation, which creates a challenge in a training environment in which one's knowledge base and clinical acumen is a constant work in progress. Moreover, poor communication contributes to problematic patient care and decreased patient satisfaction. Knowing this, we believe it is imperative that residents be formally trained in this important skill. In this article, we introduce and highlight the most recent advances in standardized approaches to the referral-consultation process, including the 5C (contact, communicate, core question, collaborate, close the loop), PIQUED (prepare, identify, question, urgency, educational modifications, debrief), and CONSULT (contact courteously, orient, narrow question, story, urgency, later, thank you) models. Common roadblocks and complicating factors involved in resident-consultant interaction are also reviewed, ending with best-practice recommendations for consultants involved in resident education, as well as free open access medical education resources.
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Affiliation(s)
- Jared Baylis
- Department of Emergency Medicine, University of British Columbia, Kelowna, British Columbia, Canada.
| | - Eli M Miloslavsky
- Department of Medicine, Division of Rheumatology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Rob Woods
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Teresa M Chan
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Cross R, Considine J, Currey J. Nursing handover of vital signs at the transition of care from the emergency department to the inpatient ward: An integrative review. J Clin Nurs 2018; 28:1010-1021. [DOI: 10.1111/jocn.14679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 09/03/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rachel Cross
- School of Nursing and Midwifery Deakin University Burwood Victoria Australia
- School of Nursing and Midwifery La Trobe University Melbourne Victoria Australia
| | - Julie Considine
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
- Centre for Quality and Patient Safety Research Eastern Health Partnership Box Hill Victoria Australia
| | - Judy Currey
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
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Singleton JM, Sanchez LD, Masser BA, Reich B. Efficiency of electronic signout for ED-to-inpatient admission at a non-teaching hospital. Intern Emerg Med 2018. [PMID: 29516433 DOI: 10.1007/s11739-018-1816-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Admission handoff is a high-risk component of patient care. Previous studies have shown that a standardized physician electronic signout ("eSignout") may improve ED-to-inpatient handoff safety and efficiency in teaching hospitals. This model has not yet been studied in non-teaching hospitals. The objectives of the study were to determine the efficiency of an eSignout platform at a community affiliate hospital by comparing ED length of stay (LOS) for a 5-month period before and after implementation and to compare the quality assurance (QA) events among admitted patients for the same time period. A retrospective, interventional study was conducted with the main outcome measures including ED LOS with calculation of 95% CI, mean comparison (t test), and number of QA events before and after implementation of the eSignout model. Prior to eSignout implementation, 1045 patients were admitted [mean ED LOS 330.0 min (95% CI 318.6-341.4)]. Following implementation, 1106 patients were admitted [mean ED LOS 338.9 min (95% CI 327.4-350.4, p = 0.2853)]. Nine pre-implementation QA events and six post-implementation events were identified. Use of a physician eSignout in a non-teaching hospital had no statistically significant effect on ED LOS for the admitted patients. The effect of an electronic interdepartmental handoff tool for patient safety and clinical operations in the non-teaching setting is unclear.
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Affiliation(s)
- Jennifer M Singleton
- Instructor of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA.
| | - Leon D Sanchez
- Vice Chair of Clinical Operations, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Barbara A Masser
- Medical Director, Urgent Care, Beth Israel Deaconess Medical Center, Boston, USA
| | - Betzalel Reich
- Instructor of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA
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Safe Passage: Improving the Transition of Care Between Triage and Labor and Delivery. Qual Manag Health Care 2018; 27:223-228. [DOI: 10.1097/qmh.0000000000000191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gonzalez CE, Brito-Dellan N, Banala SR, Rubio D, Ait Aiss M, Rice TW, Chen K, Bodurka DC, Escalante CP. Handoff Tool Enabling Standardized Transitions Between the Emergency Department and the Hospitalist Inpatient Service at a Major Cancer Center. Am J Med Qual 2018; 33:629-636. [PMID: 29779398 DOI: 10.1177/1062860618776096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution's ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% ( P = .393), the number of rapid-response team calls by 39% ( P = .637), and time to inpatient order by 31% ( P = .004). ED physicians' and hospitalists' satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot ( P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.
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Affiliation(s)
| | | | - Srinivas R Banala
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX.,2 Baylor College of Medicine, Houston, TX
| | - David Rubio
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mohamed Ait Aiss
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Terry W Rice
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Chen
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane C Bodurka
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
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Balhara KS, Peterson SM, Elabd MM, Regan L, Anton X, Al-Natour BA, Hsieh YH, Scheulen J, Stewart de Ramirez SA. Implementing standardized, inter-unit communication in an international setting: handoff of patients from emergency medicine to internal medicine. Intern Emerg Med 2018; 13:385-395. [PMID: 28155017 DOI: 10.1007/s11739-017-1615-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/18/2017] [Indexed: 01/20/2023]
Abstract
Standardized handoffs may reduce communication errors, but research on handoff in community and international settings is lacking. Our study at a community hospital in the United Arab Emirates characterizes existing handoff practices for admitted patients from emergency medicine (EM) to internal medicine (IM), develops a standardized handoff tool, and assesses its impact on communication and physician perceptions. EM physicians completed a survey regarding handoff practices and expectations. Trained observers utilized a checklist based on the Systems Engineering Initiative for Patient Safety model to observe 40 handoffs. EM and IM physicians collaboratively developed a written tool encouraging bedside handoff of admitted patients. After the intervention, surveys of EM physicians and 40 observations were subsequently repeated. 77.5% of initial observed handoffs occurred face-to-face, with 42.5% at bedside, and in four different languages. Most survey respondents considered face-to-face handoff ideal. Respondents noted 9-13 patients suffering harm due to handoff in the prior month. After handoff tool implementation, 97.5% of observed handoffs occurred face-to-face (versus 77.5%, p = 0.014), with 82.5% at bedside (versus 42.5%, p < 0.001), and all in English. Handoff was streamlined from 7 possible pathways to 3. Most post-intervention survey respondents reported improved workflow (77.8%) and safety (83.3%); none reported patient harm. Respondents and observers noted reduced inefficiency (p < 0.05). Our standardized tool increased face-to-face and bedside handoff, positively impacted workflow, and increased perceptions of safety by EM physicians in an international, non-academic setting. Our three-step approach can be applied towards developing standardized, context-specific inter-specialty handoff in a variety of settings.
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Affiliation(s)
- Kamna S Balhara
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, MC 7736, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Susan M Peterson
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mohamed Moheb Elabd
- Department of Emergency Medicine, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Linda Regan
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Xavier Anton
- Department of Emergency Medicine, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Basil Ali Al-Natour
- Department of Emergency Medicine, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - James Scheulen
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Smith CJ, Buzalko RJ, Anderson N, Michalski J, Warchol J, Ducey S, Branecki CE. Evaluation of a Novel Handoff Communication Strategy for Patients Admitted from the Emergency Department. West J Emerg Med 2018; 19:372-379. [PMID: 29560068 PMCID: PMC5851513 DOI: 10.5811/westjem.2017.9.35121] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/19/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs. Methods We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey. Results The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency. Conclusion Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.
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Affiliation(s)
- Christopher J Smith
- University of Nebraska Medical Center, Department of Internal Medicine, Omaha, Nebraska
| | | | - Nathan Anderson
- University of Nebraska Medical Center, Department of Internal Medicine, Omaha, Nebraska
| | - Joel Michalski
- University of Nebraska Medical Center, Department of Internal Medicine, Omaha, Nebraska
| | - Jordan Warchol
- George Washington School of Medicine & Health Sciences, Department of Emergency Medicine, Washington, District of Columbia
| | - Stephen Ducey
- Salt Lake Regional Medical Center, Department of Emergency Medicine, Salt Lake, Utah
| | - Chad E Branecki
- University of Nebraska Medical Center, Department of Emergency Medicine, Omaha, Nebraska
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John RL, Antai-Otong D. Contemporary Treatment Approaches to Major Depression and Bipolar Disorders. Nurs Clin North Am 2017; 51:335-51. [PMID: 27229286 DOI: 10.1016/j.cnur.2016.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Mood disorders have a high incidence of coexisting psychiatric, substance use, and physical disorders. When these disorders are unrecognized and left untreated, patients are likely to have a reduced life expectancy and experience impaired functional and psychosocial deficits and poor quality of life. Psychiatric nurses are poised to address the needs of these patients through various approaches. Although the ideal approach for mood disorders continues to be researched, there is a compilation of data showing that integrated models of treatment that reflect person-centered, strength, and recovery-based principles produce positive clinical outcomes.
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Affiliation(s)
- Richard L John
- Department of Veterans Affairs-Greater Los Angeles, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.
| | - Deborah Antai-Otong
- Department of Veterans Affairs, Veterans Integrated Service Networks-(VISN-17), 2301 E. Lamar Boulevard, Arlington, TX 76006, USA
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Lee S, Jordan J, Hern HG, Kessler C, Promes S, Krzyzaniak S, Gallahue F, Stettner T, Druck J. Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm. West J Emerg Med 2016; 18:86-92. [PMID: 28116015 PMCID: PMC5226771 DOI: 10.5811/westjem.2016.9.31004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/30/2016] [Accepted: 09/30/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting. Methods This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff. Results 121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or face-to-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting. Conclusion Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey’s assessment of needs.
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Affiliation(s)
- Sangil Lee
- The University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Jaime Jordan
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California
| | - H Gene Hern
- Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Chad Kessler
- Duke University, Department of Emergency Medicine and Internal Medicine, Durham, North Carolina
| | - Susan Promes
- Pennsylvania State University, Department of Emergency Medicine, State College, Pennsylvania
| | - Sarah Krzyzaniak
- University of Illinois at Peoria, Department of Emergency Medicine, Peoria, Illinois
| | - Fiona Gallahue
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Ted Stettner
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Jeffrey Druck
- University of Colorado, Department of Emergency Medicine, Aurora, Colorado
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Khan A, Furtak SL, Melvin P, Rogers JE, Schuster MA, Landrigan CP. Parent-Reported Errors and Adverse Events in Hospitalized Children. JAMA Pediatr 2016; 170:e154608. [PMID: 26928413 PMCID: PMC5336322 DOI: 10.1001/jamapediatrics.2015.4608] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Limited data exist regarding the incidence and nature of patient- and family-reported medical errors, particularly in pediatrics. OBJECTIVE To determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective cohort study from May 2013 to October 2014 within 2 general pediatric units at a children's hospital. Included in the study were English-speaking parents (N = 471) of randomly selected inpatients (ages 0-17 years) prior to discharge. Parents reported via written survey whether their child experienced any safety incidents during hospitalization. Two physician reviewers classified incidents as medical errors, other quality issues, or exclusions (κ = 0.64; agreement = 78%). They then categorized medical errors as harmful (ie, preventable AEs) or nonharmful (κ = 0.77; agreement = 89%). We analyzed errors/AEs using descriptive statistics and explored predictors of parent-reported errors using bivariate statistics. We subsequently reviewed patient medical records to determine the number of parent-reported errors that were present in the medical record. We obtained demographic/clinical data from hospital administrative records. MAIN OUTCOMES AND MEASURES Medical errors and preventable AEs. RESULTS The mean (SD) age of the 383 parents surveyed was 36.6 (8.9) years; most respondents (n = 266) were female. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Among these, 62% (n = 23, 6.0 per 100 admissions) were determined to be medical errors on physician review, 24% (n = 9) were determined to be other quality problems, and 14% (n = 5) were determined to be neither. Thirty percent (n = 7, 1.8 per 100 admissions) of medical errors caused harm (ie, were preventable AEs). On bivariate analysis, children with medical errors appeared to have longer lengths of stay (median [interquartile range], 2.9 days [2.2-6.9] vs 2.5 days [1.9-4.1]; P = .04), more often had a metabolic (14.3% vs 3.0%; P = .04) or neuromuscular (14.3% vs 3.6%; P = .05) condition, and more often had an annual household income greater than $100,000 (38.1% vs 30.1%; P = .06) than those without errors. Fifty-seven percent (n = 13) of parent-reported medical errors were also identified on subsequent medical record review. CONCLUSIONS AND RELEVANCE Parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record. Families are an underused source of data about errors, particularly preventable AEs. Hospitals may wish to consider incorporating family reports into routine safety surveillance systems.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Stephannie L. Furtak
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Jayne E. Rogers
- Department of Nursing, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts5Division of Sleep Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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