National Safety Goals Research Articles

Electronic charting of transfusion medicine consults: implementation, challenges and opportunities.

The Joint Commission lists improving staff communication (handoffs) as part of several National Safety Goals. In this study, we developed an electronic web-based charting system for clinical pathology handoffs, which primarily consist of transfusion medicine calls, and evaluated the advantages over a paper-based handwritten call log. A secure online web browser application using Research Electronic Data Capture (REDCap) was designed to document on-call pathology resident consults. A year after implementation, an online survey was administered to our pathology residents in order to evaluate and compare the usability of the electronic application (e-consults) to the previous handwritten call log, which was a notebook where trainees hand wrote different components of the consult. The REDCap web-based application includes discrete fields for patients' information, requesting physician contact, type of consult, action items for follow-up and faculty responses, as well as other information. These components have eventually progressed to be an online consult call catalog. With approximately 1079 consults per year, transfusion medicine-related calls account for ~90% of the encounters, while clinical chemistry, microbiology and immunology calls constitute the remainder. The overall response rate of the survey was 96% (29 of 30 participants). Of the 16 respondents who experienced both call log systems, 100% responded that REDCap was an improvement over the handwritten call log (P<0·0001). E-consult documentation entered into a web-based application was a user-friendly, secure clinical information access and effective handoff system as compared to a paper-based handwritten call log.

359 Assessment of Utilizing a Standardized Checklist on Length of Time for Resident Physician Sign Out and Attending Physician Grading Consistency

Transitions of patient care during physicians’ change of shift introduce the potential for critical information to be missed or distorted, resulting in possible morbidity. Since 2009, the Joint Commission has encouraged improving transitions of care as a national safety goal. Our study sought to determine if utilization of a sign out checklist during emergency medicine (EM) resident transition of care affected the consistency of attending physician overall assessment and if the checklist changed length of time to sign out. This prospective study assessed EM residents’ transition of care during departmental group sign out. After institutional review board (IRB) approval, residents of varying post-graduate years transferred their patients’ care to the incoming physician team. For two months, residents gave their typical sign out (pre-checklist cohort, PCL). For the next two months, residents utilized a standardized sign out checklist (post checklist cohort, CL). The incoming and outgoing attending physicians would assess each resident sign out, and give an overall assessment using a visual analogue scale. Intraclass correlation coefficients (ICC) using a two-way mixed model were calculated to determine the association between the two attending physician grades. ICCs were calculated for the PCL and CL cohorts. The time was also recorded from first patient sign out to last. Continuous data are reported as medians, with separate Wilcoxon signed rank tests conducted as appropriate. Assessment of transition of care was performed for 77 days (38 days of status quo, 39 days utilizing a checklist). There were 548 assessments in the PCL cohort and 697 in the CL cohort. The ICC for PCL was 0.11 (95% confidence interval -0.18 to 0.32), which demonstrates poor consistency between attending physician graders. The ICC for CL was 0.56 (95% confidence interval 0.45 to 0.65), demonstrating a moderate consistency among attending physicians. Length of time for sign out in PCL cohort was 13 minutes, and in the CL cohort was 9 minutes. This finding was statistically significant, p = 0.03. Our study concludes that a checklist utilized during emergency medicine resident sign out improves the consistency of attending physician assessments. A standardized checklist decreases length of time to sign out with the checklist.

Validating a Multifactorial Falls Risk Assessment

Reducing risk of falls has been identified as a national safety goal by The Joint Commission (TJC). The purpose was to determine if the total score on the multifactorial Falls Risk Assessment accurately identifies the risk of falls in a homebound client. In addition, the study examined if any individual item had a higher predictive power with the incidence of falls. One hundred clients (> 65 years old) who sustained an avoidable fall during a home care episode of care, plus 25 home care clients in the same age range and time period, who did not fall. A retrospective chart review, including Falls Risk Assessment (FRA) performed at start of care, demographic information, specific physical therapy (PT) evaluation, and visit notes if necessary to determine if the fall met the inclusion criteria. Scores for each individual area of the assessment were collected for statistical analysis. Data were analyzed by a biostatistician using simple linear regression, t-tests, and regression of variable combinations. The total score on the multifactorial risk assessment tool was shown to have a strong relationship with incidence of falls. The average scores of individuals who fell after assessment were significantly higher than those of individuals who did not fall. No single factors were found to be highly predictive. A single approach to decreasing falls is likely to be less effective than a multipronged approach. Caregivers and providers are advised to consider the entirety of the falls risk and direct comprehensive interventions to address the multiple factors that lead to falls.

Minimizing Warfarin Associated Adverse Events in Hospitalized Adults: Education with Daily Reinforcement is Effective

Introduction/Objective: Warfarin, an oral anticoagulant, is commonly used to prevent thrombo-embolism. The National Safety Goals (3E) 2008, recommend that institutions develop processes to monitor safe warfarin use. Still, Adverse Drug Events (ADEs), especially bleeding are common. This PI initiative tracked warfarin dosing and ADEs linked to warfarin use in hospitalized patients with an aim to improve safe warfarin use through education, monitoring and daily reinforcement.

Warfarin: Implementing Its Safe Use in Hospitalized Patients from Nursing Homes and Community Through a Performance Improvement Initiative

Warfarin is increasingly used to prevent thromboembolism but adverse drug events (ADEs) are common. The National Safety Goals (3E) 2008 recommend that institutions develop processes to monitor the safe use of warfarin. Despite these guidelines, adverse events (bleeding) are common. This initiative, in an academic hospital, tracked warfarin use before and after using a PI process aimed at improving safe use of warfarin in hospitalized adults. Retrospective (PRE-initiative, September-December 2007) and prospective (POST-initiative, January-December 2008) data were collected on in-hospital and prior warfarin use, demographics, medical history, initial and in-hospital warfarin maintenance dosing, hematocrit, International Normalized Ratio (INR), hepatic and renal function and adverse events related to warfarin use. Education on the appropriate use of warfarin was provided through formal and informal sessions and during daily hand-off sessions. A total of 308 patients receiving oral warfarin were examined (mean age 70 ± 17(SD) years, 47% males, 36% from nursing homes). Age, sex ratios, and place of residence were similar PRE- versus POST-initiative. Overall initial and maintenance warfarin doses were significantly lower POST-initiative (P = .0129 and P = .0319, respectively) and these decreases occurred exclusively in patients with supratherapeutic INR levels (>3.0). During the POST-period, the prevalence of high INR levels and bleeding events during hospitalization also decreased significantly (P = .015 and P < .0005, respectively). Finally, concomitant use of anticoagulant and/or antiplatelet drugs was significantly decreased POST-initiative (P = .028). Most hospitalized patients (PRE- and POST-) presented with INRs in the sub- or supratherapeutic ranges (<2 and >3, respectively), requiring warfarin dose adjustments. Education through this initiative resulted in significantly lower average maintenance doses of warfarin, less use of concomitant anticoagulant or antiplatelet drugs, fewer supratherapeutic range INRs, and fewer adverse events during warfarin therapy. Education through a PI initiative is a simple and effective means to implement safer use of warfarin in the in-hospital setting.