Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.

COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.

Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    

The authors discuss the challenges social inequalities pose to machine learning models, provide several recommendations for adopting ethical principles for the delivery of machine learning-assisted health care.

Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.

Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.

This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.

A formal hospital discharge transition report for patients taking warfarin was well received by outpatient physicians, but it did not appreciably affect processes of care measures or therapeutic efficacy. A postdischarge medication error involving warfarin was discussed in a previous AHRQ WebM&M commentary.

… formal error disclosure policies, and less than half had a patient advisory council. These findings demonstrate the …

This United Kingdom study of safety culture found that medical students showed varying willingness to perform safety-focused behaviors such as asking challenging questions, notifying physicians or nurses of errors, or submitting incidents to the national reporting system.

… 42.2% of hospitals in the United States had implemented a system that met federal "meaningful use" criteria (which …

This perspective recommends that information about malpractice litigation be incorporated into residency curriculum, to help trainees understand how it may affect their practice.

… low levels of knowledge with respect to quality, a disconnect between CEO perceptions of how well board chairs … performance on quality measures. The authors provide a series of strategic recommendations to close the reported … mechanisms for planning with incentives and maintaining a patient-centered focus. …

The authors describe key initiatives of the Maryland Patient Safety Center, a 2005 Eisenberg award winner, and propose that their approach can be used as a model for patient safety programs in other states.