Decrease Medication Errors Research Articles

Design of a Mixed-Reality Application to Reduce Pediatric Medication Errors in Prehospital Emergency Care

Children in prehospital emergency care are particularly vulnerable to medication errors, often with serious consequences. A prior study analyzing prehospital pediatric medication dosing errors, conducted after the implementation of a statewide pediatric drug-dosing reference for emergency medical services (EMS), identified an alarmingly high error rate. This significant finding led to the current study, which aims to develop technological interventions to reduce the frequency of medication errors for children during treatment by EMS. The current study focuses on the design and development of a safety strategy to automate medication administration using mixed-reality technology. Simulations were conducted to inform the design process, focusing on three scenarios: cardiac arrest, seizure, and burns. The design team included medical and engineering researchers, paramedics, and emergency medical technicians from multiple emergency medical service agencies. Root cause analysis (RCA) and failure mode and effects analysis (FMEA) were conducted after the simulations were completed. The RCA and FMEA were used to identify and prioritize failure points, which were then addressed in a mixed-reality solution using Microsoft HoloLens 2 to automate and enhance pediatric medication administration in prehospital emergency care. The resulting application will provide real-time assistance to guide paramedics through the complicated medication dosing and administration process using a detailed step-by-step guide, aiming to decrease medication errors and improve medication dosing accuracy.

THE IMPLEMENTATION OF ELECTRONIC-BASED SYSTEM IN REDUCTION OF MEDICATION ERROR: A LITERATURE REVIEW

Medication errors have been a persistent issue in healthcare, often overshadowing nurses' ability to focus on patient care. Traditionally, nurses have devoted considerable time to calculating medications—dosages, routes, and frequencies—at the expense of other caregiving duties. This literature review explores the adoption of electronic-based systems to reduce medication errors and associated risks in healthcare settings. The research involved examining databases such as Clinical-key-nursing, Science Direct, ProQuest, Embase, and academic articles, using keywords like "medication error" and "electronic-based system." The findings suggest that electronic systems can mitigate harms linked to medication errors by ensuring compliance with the "10 rights of medication administration," which include the right patient, drug, dose, time, route, documentation, assessment, approach, drug interaction, and information. The review analyzed 19 articles, but only ten met the inclusion criteria. The results indicate a positive correlation between the use of electronic systems and a decrease in medication errors, highlighting the potential benefits of technology in enhancing patient safety and care efficiency.

Outcomes of clinical decision support systems in real-world perioperative care: A systematic review and meta-analysis.

Although clinical decision support systems (CDSS) have been developed to enhance the quality and efficiency of surgeries, little is known regarding the practical effects in real-world perioperative care. To systematically review and meta-analyze the current impact of CDSS on various aspects of perioperative care, providing evidence support for future research on CDSS development and clinical implementation. This systematic review and meta-analysis followed the Cochrane Handbook and PRISMA statement guidelines, searching databases up to February 2, 2024, including MEDLINE, PubMed, Embase, Cochrane, and Web of Science. It included studies on the effectiveness of CDSS in assisting perioperative decision-making, involving anaesthesiologists, doctors, or surgical patients, and reporting at least one outcome such as complications, mortality, length of stay, compliance, or cost. Forty studies met inclusion criteria, analyzing outcomes from 408,357 participants, predominantly in developed countries. Most perioperative CDSS use was associated with improved guideline adherence, decreased medication errors, and some improvements in patient safety measures such as reduced postoperative nausea and vomiting and myocardial injury. However, reported results varied widely, and no significant improvement in postoperative mortality was observed. The preliminary findings of this review offer an overview of the potential use of CDSS in real-world perioperative situations to enhance patient and anaesthesiologist outcomes, but further researches with broader outcome dimensions, involving more stakeholders, and with longer follow-up periods are warranted for the critical evaluation of CDSS and then in better facilitate clinical adoption.

Educational preparedness and perceived importance on confidence in new graduate registered nurses' medication administration

BackgroundMedication errors are the most common type of error affecting patient safety and the most preventable cause of adverse medical events globally. Medication errors occur most frequently (33.3 %) during the administration phase. New nurses felt their education left them vulnerable to errors, suggesting that current curricula may be insufficient. PurposeThe purpose of this study was to determine the relationship between new nurses' educational preparedness and perceived importance with confidence in medication administration. A secondary aim was to determine the difference in the variables based on demographic information. MethodsA descriptive, correlational design was employed using the Theory of Human Error. Ohio newly licensed nurses were surveyed for their educational preparedness, perceived importance, and confidence in nine medication competencies. Descriptive and inferential statistics were used. ResultsN = 201. A significant, positive relationship was found between both educational preparedness and confidence, and perceived importance and confidence. Nurses reported high levels of educational preparedness, perceived importance, and confidence. All correlations and regressions were significant, indicating that as nurse educational preparedness and/or perceived importance increases, the odds of confidence increases. Demographic analysis demonstrated that practice area and years of experience significantly contributed to differences in the variables. ConclusionsUnderstanding the educational preparedness and perceived importance of the medication competencies can help guide future research into creating educational and clinical interventions to ultimately decrease medication errors.

Impact of digital health on the quadruple aims of healthcare: A correlational and longitudinal study (Digimat Study)

BackgroundDigital healthcare aims to deliver on the quadruple aim: enhance patient experiences, improve population health, reduce costs and improve provider experiences. Despite large investments, it is unclear how advancing digital health enables these healthcare aims. ObjectiveOur objectives were to: 1) measure the correlation between digital capability and health system outcomes mapped to the quadruple aim, and 2) measure the longitudinal impact of electronic medical record implementations upon health system outcomes. Materials and methodsWe undertook two studies: 1) Digital health correlational study investigating the association among healthcare system capability and healthcare aims, and 2) Digital hospital longitudinal study investigating outcomes pre and post electronic medical record implementation. ResultsDigital health capability was associated with lower staff turnover. Digitising healthcare services was associated with decreased medication errors, decreased nosocomial infections, increased hospital activity, and a transient increase in staff leave. DiscussionThese results suggest positive impacts on the population health and healthcare costs aim, minimal impacts on the provider experience aim and no observed impacts to the patient experience aim. ConclusionThese findings should provide confidence to healthcare decision-makers investing in digital health.

Evaluation of the Effect of Smart Pump Interoperability on Infusion Errors in the Pediatric Hospital Setting.

Smart pump interoperability is a newer technology integrating intravenous medication -infusion instructions from the electronic medical record into a smart pump. This technology has demonstrated significantly decreased medication errors in the adult population; however, this has not been reported in pediatrics. The purpose of this study was to compare the frequency and severity of infusion related errors before and after the implementation of smart pump interoperability at a pediatric institution. This was a retrospective study conducted at multiple institutions within the same health care system to assess the effect of smart pump interoperability on infusion errors. Data were retrospectively analyzed for a 6-month period prior to (January-June 2020) and after (January-June 2022) smart pump interoperability implementation. All who received medications via a smart pump were included in the analysis. Infusions were excluded if administered via a patient-controlled analgesia pump, epidural pump, or intravenously pushed without using a smart pump. A total of 143,997 versus 165,343 infusions were administered in the before versus after interoperability group. There were significant decreases in mild, moderate, and severe harm averted events once interoperability was implemented (p < 0.001). Errors caught before administration decreased after interoperability implementation from 197 events to 20 events because of fewer overall errors (p < 0.001). The number of guardrail alert overrides was significantly reduced, from 23,751 to 5885 (p < 0.001), as was the number of high-risk overrides, from 5851 to 207 (p < 0.001). Implementing smart pump interoperability significantly reduced the frequency and severity of infusion errors and high-risk overrides at a pediatric institution.

Decreasing medication errors in Alexandria Main University Hospital Critical Care Unit 3 using sensitization program

ABSTRACT Introduction The occurrence of medication errors in hospital settings presents considerable public health challenges, as they significantly affect patient morbidity and mortality, especially with an increasing frequency in critical care units. Material and methods A prospective before-and-after study conducted in Critical Care Unit 3 at Alexandria Main University Hospital involved 1440 observations of medication errors in 16-bed units over three months, encompassing 181 patients using a checklist. After implementing a sensitization program, a follow-up study was conducted with 1472 observations involving 185 patients over another three months. The comprehensive study focuses on the impact of the sensitization program on medication errors and its reporting, employing a prospective before-after design. Results No statistically significant difference in mortality was observed between Control and Postintervention groups (p = 0.258). Prescription errors accounted for 52.0%, transcription errors 19.2%, dispensing errors 1.2%, preparation errors 13.9%, and administration errors 13.6% of total medication errors. In the Control group, 38.7% experienced at least one medical error, compared to 21.6% in the Postintervention group (p < 0.001). There were 396 medication errors (27.5% of observations) in the Control group versus 250 errors (17.0% of observations) in the Postintervention group (p < 0.001). Errors reporting increased from 3.8% to 30% (p < 0.001). Conclusions The non-technological sensitization program effectively reduced medication errors in our resource-limited unit and improved error reporting.

Interventional cardiologists' perspectives and knowledge towards artificial intelligence.

Artificial intelligence (AI) is increasingly utilized in interventional cardiology (IC) and holds the potential to revolutionize the field. We conducted a global, web-based, anonymous survey of IC fellows and attendings to assess the knowledge and perceptions of interventional cardiologists regarding AI use in IC. A total of 521 interventional cardiologists participated in the survey. The median age range of participants was 36 to 45 years, most (51.5%) practice in the United States, and 7.5% were women. Most (84.7%) could explain well or somehow knew what AI is about, and 63.7% were optimistic/very optimistic about AI in IC. However, 73.5% believed that physicians know too little about AI to use it on patients and most (46.1%) agreed that training will be necessary. Only 22.1% were currently implementing AI in their personal clinical practice, while 60.6% estimated implementation of AI in their practice during the next 5 years. Most agreed that AI will increase diagnostic efficiency, diagnostic accuracy, treatment selection, and healthcare expenditure, and decrease medical errors. The most tried AI-powered tools were image analysis (57.3%), ECG analysis (61.7%), and AI-powered algorithms (45.9%). Interventional cardiologists practicing in academic hospitals were more likely to have AI tools currently implemented in their clinical practice and to use them, women had a higher likelihood of expressing concerns regarding AI, and younger interventional cardiologists were more optimistic about AI integration in IC. Our survey suggests a positive attitude of interventional cardiologists regarding AI implementation in the field of IC.

Enhancing Hospital Pharmacy Operations Through Lean and Six Sigma Strategies: A Systematic Review.

Hospital pharmacies are integral to the healthcare system, and evaluating the factors influencing their efficiency and service standards is imperative. This analysis offers global insights to assist in developing strategies for future enhancements. The objective is to identify the optimal Lean Six Sigmamethodologies to improve workflow and quality of hospital pharmacy services. A strategic search, aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, encompassed an extensive range of academic databases, including Scopus, PubMed/Medline, Web of Science, and other sources for relevant studies published from 2009 to 2023. The focus was on management tactics and those examining outcomes, prioritizing publications reflecting pharmacy operations management's state. The quality of the selected articles was assessed, and the results were combined and analyzed. The search yielded 1,447 studies, of which 73 met the inclusion criteria. The systematic review found a low to moderate overall risk of bias. The number of publications roseduring the coronavirus disease (COVID-19) outbreak. Among studies, research output in the United States of Americarepresented26% of the total. Other countries such asIndonesia, Spain, Canada, China, Saudi Arabia, the United Arab Emirates, and the United Kingdom also made significant contributions. Each country accounted for 12%, 8%, 7%, 5%, 5%, 5%, and 5%, respectively. The pharmacy journals led with26 publications, and healthcare/medical with 14. The quality category came next with 12 articles, whileseven journals represented engineering.Studies used empirical and observational methods, focusing on practice quality enhancement. The process control plan had 26 instances, and the define, measure, analyze, improve, and control (DMAIC) was identified 13 times. The sort, set in order, shine, standardize, and sustain (5S)ranked third, totaling seven occurrences. Failure mode and effects analysis (FMEA) and root cause analysiswere moderately utilized, with six and four instances, respectively. Poka-Yoke (mistake-proofing measures) and value stream mappingwere each counted three times.Quality improvement and workflow optimization dominated managerial strategies in 22 (30.14%) studies each, followed by technology integration in 15 (20.55%). Cost, patient care, and staffing each featured in three (4.11%) studies, while two (2.74%) focused on inventory management. One (1.37%) study each highlighted continuing education, collaboration, and policy changes. Analysis of the 73 studies on Lean and Six Sigma in hospital pharmacy operations showed significant impacts, with 26% of studies reporting decreased medication turnaround time, 15% showing process efficiency improvements, and 11% each for enhanced inventory management and bottleneck/failure mode reduction. Additionally, 9% of studies observed decreased medication errors, 8% noted increased satisfaction and cost savings, 6% identified enhancements in clinical activities, 3% improved prescription accuracy, 2% reduced workflow interruptions, and 1% reported increased knowledge.Also, this study has identified key strategies for service delivery improvement and the importance of quality practices and lean leadership. To the best of the author's knowledge, this research is believed to be the first in-depth analysis of Lean and Six Sigma in the hospital pharmacy domain, spanning 15 years from 2009 to 2023.

Nurses thoughts on using drugs database created by clinical pharmacist as help tool for preparation and administration of drugs

Background/Aim: Intravenous therapy is a complex process usually requiring the preparation of the medicine before administration to the patient and it is well known that errors in preparation and administration can cause harm to patient. Systems that use information technology are key components of strategies to prevent medication errors in developed countries. Therefore, aim of study was to investigate nurses' perspective on medicines database in clinical information system implemented in university hospital. Methods: A convenience sample of 79 nurses at the bedside from four different hospital wards in the 1200-bed university hospital were asked to participate in the study. The questionnaire included twenty-three questions organised in three different sections and it assessed 3 components of the medicines usage: (1) medicines preparation; (2) medicines administration; (3) clinical information system usage. Mean scores were calculated for the 4-item Likert-type scale. Results: Most nurses found information in drug database reliable (Likert scale mean = 1.42 ± 0.778) and believed that using medicines database can decrease drug preparation and drug administration errors (mean: 1.35 ± 0.717) with no significant difference in mean between four different wards. Similarly, most nurses were familiar with the drug database in clinical information system (mean: 1.22 ± 0.613). Conclusion: Pharmacist as a drug expert could introduce medicines database to nurses, train them how to use it in everyday practice and explain how using information technologies can help in decreasing medication errors which leads to increasing patients' safety during hospitalisation.

Implementation of pharmacy-led preoperative medication reconciliation in surgical oncology patients

BackgroundPharmacy-led medication history collection and reconciliation have demonstrated decreased medication errors, increased patient safety, and improved cost-savings. However, literature lacks documented efforts to implement such services in the preoperative space, where having accurate medication lists following complex procedures with high postoperative admission rates is critical. ObjectivesThe purpose of this study was to describe the implementation of a telephonic pharmacy student and pharmacist-led preoperative medication reconciliation program. Practice descriptionThe service was piloted using third- and fourth-year pharmacy students to conduct telephonic medication histories for urologic surgical oncology patients. Weekly reports identified eligible patients with scheduled procedures within 2 weeks’ time. Using standardized methods for patient communication and documentation, students authored telephone encounter notes that were reviewed and signed by pharmacist preceptors. Pharmacist preceptors also reconciled home medication lists based on students’ findings. Practice innovationA standardized preoperative medication reconciliation process was developed and implemented utilizing third- and fourth-year pharmacy students. Resulting notes were available for surgical staff on the day of patients’ procedures and upon potential postoperative admission. Evaluation methodsA retrospective chart review was conducted to evaluate successfully documented medication histories collected by pharmacy students within the pharmacy-led preoperative medication reconciliation program. ResultsForty-six medication reconciliation notes were identified between August 2021 and February 2022, and 39 met inclusion criteria. Amongst the 177 medication additions, deletions, and edits, deletions were the most common, and 95% of patients had at least 1 medication discrepancy identified. A total of 33 medication classes were represented by the identified discrepancies, and each encounter took an average of 33 minutes to complete. ConclusionPreoperative medication reconciliation services can be successfully accomplished through a telephonic pharmacy student and pharmacist-led workflow. Accurate medication histories aid in minimizing medication errors and increasing patient safety.

Leadership Role In Implementation Of Lean Manajemen In Hospital

&lt;p&gt;&lt;em&gt;Hospitals in Indonesia are facing the era of JKN (National Health Insurance) with a focus on cost efficiency and service quality, where the implementation of Lean management has been proven to successfully increase patient satisfaction, reduce waiting time, and decrease medical errors. This study aims to synthesize the research findings on the role of leadership in the success of Lean management in hospitals during the period of 2018-2023. &lt;/em&gt;&lt;em&gt;The research design used in this article is scoping review. The selection method in this review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Article search was performed through international journal databases including Google Scholar, PubMed, Sciencedirect, and Emerald published between 2018-2022. The result shows a total of 176 articles were obtained from four databases, namely Google Scholar, PubMed, Sciencedirect, and Emerald. Selection was performed, and 20 articles were considered eligible and included in the systematic review. Leadership, including lean leadership and management, plays a crucial role in the success of Lean management implementation in hospitals, with transformational leadership style recognized as the most effective, but it requires long-term commitment and faces challenges of resistance to change and lengthy implementation time. &lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt; &lt;/em&gt;&lt;/p&gt;&lt;strong&gt;&lt;em&gt;Keywords: Hospital, Implementation,&lt;/em&gt;&lt;/strong&gt;&lt;em&gt; &lt;strong&gt;Leadership, Lean Management, Meta-Analysis.&lt;/strong&gt;&lt;/em&gt;

Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project

BackgroundMedication errors and adverse drug events have a significant impact on mortality and morbidity among hospitalized children, and are more likely to occur in critical care settings due to the fast-paced environment and patient vulnerability. There is no exception to this rule in our pediatric intensive care unit, a 28-bed unit at a tertiary care children's hospital in Riyadh, Saudi Arabia. Problem assessmentA medication administration error rate of 6.25–8.05/1000 patient days was reported in our unit (48 errors), taking into account only errors that reached patients. Toward improving patient safety, a project was launched to reduce medication errors. DesignMultidisciplinary quality improvement team reviewed baseline data and analyzed medication errors that occurred in 2019. Five Plan-Do-Study-Act cycles were implemented. As an outcome measure, the medication error rate was monitored. ResultsThe outcome measure of medication administration error rates was monitored quarterly. An improvement of 75% during the first quarter of 2021 to a rate of zero medication errors/1000 patient days during the first quarter of 2022. A decrease in medication errors was attributed to improved situational awareness and increased compliance with assisted technology. ConclusionMedication errors can be decreased by deploying various interventions utilizing human- and technology-based approaches. When it comes to reducing medication errors in the pediatric intensive care unit, a multidisciplinary approach is paramount. Implications for clinical practiceThis study suggests several ways to reduce medication errors. Implementing information technology systems and involving pharmacists in medication management can help prevent errors. Enhancing teamwork, communication, and collaboration among healthcare professionals is also important. Clinical risk management strategies, nursing interventions, and adherence to medication safety guidelines are essential, especially for pediatric and neonatal populations. Considering these clinical implications can guide healthcare professionals and organizations in addressing medication errors and enhancing patient safety.

Medication safety in pediatric anesthesia: An educational review and a call to action.

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.

Impact of extramural DAIT/NIAID pharmacy programs, research pharmacist scientist oversight on study performance, and lessons learned

PurposeOver the past two decades, the involvement of a Pharmacist Scientist in clinical settings has improved patient safety, decreased medication errors, and enabled successful conduct of clinical trials and faster product development [1–5]. The impact of an oversight by a Pharmacist Scientist on clinical trial performance and execution in terms of Pharmacy and Investigational Product (IP)-related deviations has not been evaluated by a sponsor. MethodsThis was a retrospective observational study conducted by the Division of Allergy, Immunology and Transplantation (DAIT), National Institute of Allergy and Infectious Diseases (NIAID). We assessed the association of the number of Pharmacy and Investigational Product (IP)-related deviations with Pharmacist oversight and use of DAIT Pharmacy/ Pharmaceutical services in two groups: Intervention Group (IG) and the Control Group (CG). ResultsWe evaluated monitoring data from 116 studies conducted between 2006 through 2020. Forty-one eligible clinical trials were included and analyzed: 13 trials were in the IG with Pharmacist oversight and use of Pharmacy Services; 28 trials were in the CG with no Pharmacist oversight and zero to partial use DAIT Pharmacy/ Pharmaceutical Services. The evaluation revealed the expected risk of having a pharmacy and IP-related deviations were 2.94 times higher (95% CI 1.28, 6.67, = 0.01) in trials not having Pharmacist oversight and zero to partial use of Pharmaceutical/ Pharmacy Program services. This significant finding was associated with having Pharmacist oversight when adjusting for study size (# of sites and patients needed), anticipated study duration, design complexity, and whether recruitment was completed or not. ConclusionWe found a statistically significant association between Pharmacist Scientist involvement and oversight from protocol development to study execution and a reduction in Pharmacy and IP-related deviations.

Decreasing Medication Errors at Discharge: A Quality Improvement Project.

Decreasing Medication Errors at Discharge: A Quality Improvement Project.

Unlocking Performance Excellence: Review of Evidence-Based Mindful Meditation.

Mindfulness has recently been implemented by advanced military combatants, firefighters, and those in other very intellectually demanding and fast-paced professions. A surgeon, similarly, is faced with many difficult challenges, whether it be a complex and meticulous surgery, extensive clinical responsibilities, or simply the challenges faced in residency. In current curricula, there is no training to introspectively deal with these stressors. Regardless of what we face in our personal lives, the lives of patients are literately in our hands. Would it not be prudent and wise to train our brain to not only deliver care to our patients but also be able to take care of us and maybe even improve our performance? Regular practice of mindfulness has been shown to decrease rates of burnout, decrease medical errors, improve sleep, and even improve surgical performance. With the ever-changing pandemic situation and increasing stressors in the hospital, mindful meditation is perfectly primed to be added to our armamentarium as surgeons and physicians. This review aims to explain how mindfulness can enhance a surgeon's performance, mindset, interactions, and execution through a review of recent scientific advancements and evidence.

Healthcare Proctoring System Using Chatbot Based on Machine Learning

This presentation describes the implementation of a healthcare portal which will include features like interoperability, symptom-based disease prediction with the help of a chatbot and remote patient health proctoring services.[1] As it is common knowledge, health and medicine are gaining a lot of significance in today’s advancing world, where evolving technology is being used to combat almost all the known diseases.[2] Technology is constantly developing everywhere forevery new ailment that us humans come across. We have new counter-measures ready for these diseases.[3]However, according to reports, more than 200 thousand people in China, 100 thousand in the USA,and nearly 70 thousand people in India die each yeardue to medication errors. Technologies such as data mining and other recommended technologies provide possibilities to explore potential knowledge from diagnosis history records and help doctors to diagnose the disease and prescribe medicines correctly to decrease medication error effectively.[4] This project proposes a system which will aim to negate any miscommunication between the medical professional and patient by acting as a medium whichwill be accessible by both entities with every record of the patient available for the professionals.[5] This system consists of a database system module, data preparation module, disease prediction module,medicine recommendation module, model evaluation and API which will be used for a centralized database for the patient’s data.[6] A decisiontree map and random forest algorithm are used to achieve the objective. This paper also mentions the additional features of the proposed system like the dual function of prediction of diseases and the recommendation of medicines, which adds to the capabilities of the existing systems, and has a portal through which a patient can have appointments, get reports for every medical check-up which will be virtually available. The patient’s data will be globally available for both medical professionals as well as the patient to see.[7] The proposed system will be designed in such a waythat every user’s data will be regularly updated in case it is being monitored by other attending medicalprofessionals.[8] Keywords healthcare portal, recommendation

Limited English proficiency in the labor and delivery unit.

Limited English proficiency (LEP) impacts patient access to safe and comprehensive care during the antepartum, intrapartum, and postpartum periods. In this review, we explore disparities in care delivery and outcomes that LEP women experience, and discuss the importance of providing language concordant care and using interpretation services appropriately. The number of individuals with LEP is steadily increasing in the United States. Pregnant women with LEP suffer disparities in obstetric care and are at risk for postpartum depression, breastfeeding difficulties, and substandard newborn care after neonatal ICU discharge because of insufficient education. Addressing these issues requires the implementation of language concordant care and education, along with the utilization of medically trained interpreters. Although further evidence is needed, the authors support these interventions to improve patient satisfaction, decrease medical errors, and curtail misdiagnoses. The pregnant woman with limited English proficiency is at risk of receiving suboptimal care and experiencing negative outcomes during the antepartum, intrapartum, and postpartum periods. The use of medically trained interpreters and the provision of language concordant care, through workforce diversification and the creation of forms and educational materials in diverse languages, can improve patient safety, outcomes, and quality of care.

Improving Continuity of Care of Patients Transferred Between Medical and Psychiatry Wards During the COVID-19 Pandemic and the Increasing Demands on Core Trainees to Manage Medical CoMorbidity

AimsAn existing transfer document at FVRH recognised that patients presenting to one specialty may require transfer to another depending on the changing needs of that patient. This document was not often used prior to the COVID-19 pandemic however demands for medical beds resulting in prompt return of patients to psychiatry highlighted the need to adhere to a safe transfer process. Unlike many psychiatry units where physically unwell patients are taken to ED, the MHU for Forth Valley is attached to the general hospital. This results in the view that physically unwell patients can be managed for longer before requiring transfer. Despite the proximity to the medical wards however, the unit is not equipped to manage physically deteriorating patients. This QI project aimed to improve communication between psychiatry and medical staff to improve patient safety.MethodsPatients transferred during their admission between the MHU and medical or surgical wards in May 2020, or in Oct-Dec 2021 were identified from 5 psychiatry wards. Electronic and paper notes were checked for a transfer form for each stage of transfer. Medications prior to transfer, on return and changes during admission were cross checked on Hepma, ECS and care partner as well as within documentation from medicine/surgery.ResultsIn May 2020, no patients admitted from medical wards had a transfer form completed, 62.5% transferred to medicine and 57.1% returned from medical wards had forms. 20% of transfers had medication errors Identified. After making the transfer form electronic and following hospital wide changes to the Trakcare and Hepma systems, 27.8% of patients admitted from medical wards had forms, 75.9% transferred to medicine and 72% of those returned from medicine had forms. There were no further medication errors identified. During the timeframes studied only 1 patient was transferred due to COVID-19 but 29 transfers were carried out for other acute physical issues.ConclusionChanging the documentation process to make it as easy as possible for psychiatry juniors to document treatment plans for transferred patients improved continuity of care and decreased medication errors. This also ensured that patients were medically fit to return to psychiatry wards. The range of physical comorbidities that psychiatry trainees were expected to manage extends beyond caring for patients who contract COVID -19.