Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

Harm from pediatric anesthesia-related errors is infrequent, but largely preventable. This pediatric hospital developed and implemented an anesthesia-specific checklist to be used before anesthesia induction. This study presents the types of errors identified by the checklist over the course of one year.

… Am J Med Qual … Encouraging adverse event reporting among … to improving patient safety. This hospital implemented a multi-pronged intervention – using a combination of … and long-term. … Prabhu V, Mikhly M, Chung R, et al. I-PSI: short- and long-term efficacy of a comprehensive …

… unit . Of those, four patients were found to have class I missed major diagnosis. These results underscore the need … in early deceased septic patients in the intensive care: a retrospective cohort study. Virchows Arch. …

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

Alarm fatigue contributes to distraction and can diminish care safety. This commentary reviews a single-center project that used smartphone technology to enhance cardiac monitoring. The authors describe the structure of the project, use of Plan-Do-Study-Act cycles to design the application, results of the pilot, and plans to expand the use of this technology to other units and broaden monitoring targets. A WebM&M commentary discussed harm associated with alarm fatigue.

… J Nurs Adm … Poor communication is a persistent patient … teamwork and communication in clinical practice. … Gaston T, Short N, Ralyea C, Casterline G. Promoting Patient Safety: …

… consensus on clinical reasoning. These results complement a recent study that also supported adding interactive …

This qualitative analysis found that anticipatory management conversation occurred in most physician-to-physician and nurse-to-nurse verbal handoffs. The authors suggest that structured handoffs should be supplemented with additional verbal communication regarding relevant contextual information.

Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Teamwork … to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in … and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork …

… entry (CPOE) and intensive care unit staffing . … Ford EW, Short JC. The impact of health system membership on patient …

… from the Australian Incident Monitoring Study (AIMS), a team of anesthetists identified a need for 24 algorithms. Investigators created a manual to outline the management approaches and tested it …