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Consider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says 'your cancer is untreatable'. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals,1 cases like these are not systematically identified or addressed in hospital quality improvement programmes.2 As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. These cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system. 20 references

Introduction The occurrence of healthcare-associated infections (HAIs) increased during the coronavirus disease 2019 (COVID-19) pandemic,1–3 with the most substantial increase for central line-associated bloodstream infection (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia,4,5 reversing a multi-decade national trend of decreasing occurrence of these infections and leading to speculation that infection prevention practices had degraded as a result of the pandemic. Identified risk factors (Table 1) included higher comorbidity score on admission, longer LOS, admission to ICU, ventilator support, use of steroids, use of other immunosuppressive agents, and race/ethnicity. Because of the correlation between high-dose steroid use and lower age, an interaction term was included. Logistic regression for odds of HAI in patients with COVID-19 MRSA CLABSI Adjusted OR 95% CI Adjusted OR 95% CI ICU within 3 days of admission 1.41 (1.08, 1.84) 1.12 (0.92, 1.36) Mechanical ventilation within 3 days of admission 1.78 (1.30, 2.45) 1.75 (1.44, 2.13) Length of stay (days, before HAI) 1.01 (1.01, 1.01) 1.00 (1.00, 1.01) Tocilizumab or baricitinib (before HAI) 1.92 (1.43, 2.58) 1.76 (1.45, 2.13) Dexamethasone <= 6 mg (before HAI) 1.61 (1.27, 2.05) 1.19 (1.00, 1.43) Elixhauser comorbidity score 1.06 (1.05, 1.07) 1.03 (1.02, 1.04) Race/ethnicity Reference: White Black/African American 0.77 (0.55, 1.09) 1.11 (0.87, 1.42) Hispanic/Latino 1.09 (0.83, 1.43) 1.90 (1.58, 2.29) Other/unknown 1.11 (0.74, 1.65) 1.59 (1.21, 2.08) Age/high-dose steroid interaction Reference: <=65, no high-dose steroids <=65, high-dose steroids 4.40 (3.03, 6.39) 2.57 (1.96, 3.36) >65, no high-dose steroids 0.84 (0.54, 1.30) 0.72 (0.51, 1.00) >65, high-dose steroids 2.46 (1.66, 3.66) 1.77 (1.34, 2.35) Note.

We described care received by hospitalized children with COVID-19 or multi-system inflammatory syndrome (MIS-C) prior to the 2021 COVID-19 Omicron variant surge in the US. We identified hospitalized children <18 years of age with a COVID-19 or MIS-C diagnosis (COVID-19 not required), separately, from February 2020-September 2021 (n = 126 hospitals). We described high-risk conditions, inpatient treatments, and complications among these groups. Among 383,083 pediatric hospitalizations, 2,186 had COVID-19 and 395 had MIS-C diagnosis. Less than 1% had both COVID-19 and MIS-C diagnosis (n = 154). Over half were >6 years old (54% COVID-19, 70% MIS-C). High-risk conditions included asthma (14% COVID-19, 11% MIS-C), and obesity (9% COVID-19, 10% MIS-C). Pulmonary complications in children with COVID-19 included viral pneumonia (24%) and acute respiratory failure (11%). In reference to children with COVID-19, those with MIS-C had more hematological disorders (62% vs 34%), sepsis (16% vs 6%), pericarditis (13% vs 2%), myocarditis (8% vs 1%). Few were ventilated or died, but some required oxygen support (38% COVID-19, 45% MIS-C) or intensive care (42% COVID-19, 69% MIS-C). Treatments included: methylprednisolone (34% COVID-19, 75% MIS-C), dexamethasone (25% COVID-19, 15% MIS-C), remdesivir (13% COVID-19, 5% MIS-C). Antibiotics (50% COVID-19, 68% MIS-C) and low-molecular weight heparin (17% COVID-19, 34% MIS-C) were frequently administered. Markers of illness severity among hospitalized children with COVID-19 prior to the 2021 Omicron surge are consistent with previous studies. We report important trends on treatments in hospitalized children with COVID-19 to improve the understanding of real-world treatment patterns in this population.

Poly-anionic compounds can chelate divalent cations and dissolve calcium oxalate stone. Our objective was to assess how much concurrent irrigation with poly-anionic chelating solutions during non-contact laser lithotripsy or popcorning could improve stone ablation rate. A popcorning model was created by lowering a ureteroscope with thulium fiber laser into a test tube calyx. Begostones of matching size and mass were placed in the test tube and treated with the laser while irrigating with different iso-osmolar poly-anionic solutions. We compared 0.9% sodium chloride (NaCl), sodium citrate, sodium hexa-metaphosphate, and sodium ethylenediaminetetraacetate (EDTA) solutions. After treatment, residual stones were passed through a 1 mm sieve, and remaining fragments greater than 1 mm were weighed as remaining stone mass. Average remaining stone mass after lithotripsy with NaCl irrigation was 27.8% (± 10.0%). The average remaining stone mass after lithotripsy with hexa-metaphosphate, sodium citrate, and EDTA irrigation was 28.9% (± 13.4%), 17.5% (± 10.5%), and 9.8% (± 5.7%) respectively. Compared with NaCl, there was a 37% reduction in remaining stone mass when using citrate (p = 0.008) and a 64.7% reduction when using EDTA irrigation during lithotripsy (p < 0.001). Concurrent irrigation with citrate or EDTA solutions synergistically enhances the efficacy laser lithotripsy in this in vitro popcorning model. This may lead to tangible improvements in endoscopic stone removal outcomes; however, the effectiveness on different stone types and safety during short duration lithotripsy should be further investigated.

BackgroundLittle is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up.MethodsIn collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience.Results105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%–70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a ‘troublemaker’, ‘team is too busy’ or ‘I don’t know how’. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up.ConclusionSpeaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create ‘trouble’ may help promote open discussions about care concerns and possible errors in the ICU.

BackgroundOpenNotes, a national movement inviting patients to read their clinicians' notes online, may enhance safety through patient-reported documentation errors.ObjectiveTo test an OpenNotes patient reporting tool focused on safety concerns.MethodsWe invited 6225 patients through a patient portal to provide note feedback in a quality improvement pilot between August 2014 and 2015. A link at the end of the note led to a 9-question survey. Patient Relations personnel vetted responses, shared safety concerns with providers and documented whether changes were made.Results2736/6225(44%) of patients read notes; among these, 1 in 12 patients used the tool, submitting 260 reports. Nearly all (96%) respondents reported understanding the note. Patients and care partners documented potential safety concerns in 23% of reports; 2% did not understand the care plan and 21% reported possible mistakes, including medications, existing health problems, something important missing from the note or current symptoms. Among these, 64% were definite or possible safety concerns on clinician review, and 57% of cases confirmed with patients resulted in a change to the record or care. The feedback tool exceeded the reporting rate of our ambulatory online clinician adverse event reporting system several-fold. After a year, 99% of patients and care partners found the tool valuable, 97% wanted it to continue, 98% reported unchanged or improved relationships with their clinician, and none of the providers in the small pilot reported worsening workflow or relationships with patients.ConclusionsPatients and care partners reported potential safety concerns in about one-quarter of reports, often resulting in a change to the record or care. Early data from an OpenNotes patient reporting tool may help engage patients as safety partners without apparent negative consequences for clinician workflow or patient-clinician relationships.

To promote communication with patients after medical injuries and improve patient safety, numerous hospitals have implemented communication-and-resolution programs (CRPs). Through these programs, hospitals communicate transparently with patients after adverse events; investigate what happened and offer an explanation; and, when warranted, apologize, take responsibility, and proactively offer compensation. Despite growing consensus that CRPs are the right thing to do, concerns over liability risks remain. We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in claims volume, cost, and time to resolution and comparing them to trends among nonimplementing peer institutions. CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at some hospitals, but it did not significantly alter trends in other outcomes. None of the hospitals experienced worsening liability trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences.

The Centers for Medicare and Medicaid Services require hospitals to report on quality metrics which are used to financially penalize those that perform in the lowest quartile. Surgical site infections (SSIs) are a critical component of the quality metrics that target healthcare-associated infections. However, the accuracy of such hospital profiling is highly affected by small surgical volumes which lead to a large amount of uncertainty in estimating standardized hospital-specific infection rates. Currently, hospitals with less than one expected SSI are excluded from rankings, but the effectiveness of this exclusion criterion is unknown. Tools that can quantify the classification accuracy and can determine the minimal surgical volume required for a desired level of accuracy are lacking. We investigate the effect of surgical volume on the accuracy of identifying poorly performing hospitals based on the standardized infection ratio and develop simulation-based algorithms for quantifying the classification accuracy. We apply our proposed method to data from HCA Healthcare (2014–2016) on SSIs in colon surgery patients. We estimate that for a procedure like colon surgery with an overall SSI rate of 3%, to rank hospitals in the HCA colon SSI dataset, hospitals that perform less than 200 procedures have a greater than 10% chance of being incorrectly assigned to the worst performing quartile. Minimum surgical volumes and predicted events criteria are required to make evaluating hospitals reliable, and these criteria vary by overall prevalence and between-hospital variability.

To determine risk factors for mortality among COVID-19 patients admitted to a system of community hospitals in the United States. Retrospective analysis of patient data collected from the routine care of COVID-19 patients. System of >180 acute-care facilities in the United States. All admitted patients with positive identification of COVID-19 and a documented discharge as of May 12, 2020. Determination of demographic characteristics, vital signs at admission, patient comorbidities and recorded discharge disposition in this population to construct a logistic regression estimating the odds of mortality, particular for those patients characterized as not being critically ill at admission. In total, 6,180 COVID-19+ patients were identified as of May 12, 2020. Most COVID-19+ patients (4,808, 77.8%) were admitted directly to a medical-surgical unit with no documented critical care or mechanical ventilation within 8 hours of admission. After adjusting for demographic characteristics, comorbidities, and vital signs at admission in this subgroup, the largest driver of the odds of mortality was patient age (OR, 1.07; 95% CI, 1.06-1.08; P < .001). Decreased oxygen saturation at admission was associated with increased odds of mortality (OR, 1.09; 95% CI, 1.06-1.12; P < .001) as was diabetes (OR, 1.57; 95% CI, 1.21-2.03; P < .001). The identification of factors observable at admission that are associated with mortality in COVID-19 patients who are initially admitted to non-critical care units may help care providers, hospital epidemiologists, and hospital safety experts better plan for the care of these patients.

In the current environment, where all resources are stretched and all healthcare workers are overextended, we need to know which care delivery innovations offer the most promise. [...]we owe our thanks to O'Leary and colleagues for pursuing formal analysis of their trial of Patient-Centered Bedside Rounds (PCBR) at Northwestern Memorial Hospital in Chicago. 5 PCBR have been described previously, and are especially popular in paediatric hospitals. [...]this is perhaps the most significant contribution of this publication: the authors recognised the potential for real tradeoffs in efficiency as part of PCBR implementation, and formally evaluated the workflow impact of their intervention.