Medication reconciliation to ensure accuracy of patient medication lists has been difficult to implement. This project report describes an initiative to enhance the timeliness of medication reconciliation for pediatric inpatients. Use of Plan-Do-Study-Act cycles helped inform the evolution of the work. The authors emphasize the importance of engaging the entire care team as well as patients and families to enable completion of the process.

Patient engagement can improve identification and prevention of medication errors. This qualitative study interviewed cardiology patients about their experiences managing medications after being discharged from hospitals in the United Kingdom. The authors described various types of patient engagement in medication management as sources of system resilience.

… BMJ open … BMJ Open … Using a novel trigger tool to identify adverse events for … 14% of patients experienced at least one adverse event. A recent AHRQ WebM&M commentary discusses the emergence of trigger tools as a patient safety measure. …

This case study illustrates the practical application of human factors engineering in designing the physical environment and equipment of an inpatient ward to minimize preventable harm.

… Safety Science … Saf Sci … This article proposes a new way of defining safety culture based on how the fields …

… drug events (based on age and comorbidities) received a high-risk prescription in the past year, particularly for …

… The Journal of emergency medicine … J Emerg Med … Nearly 20% of emergency department personnel … affected patient safety. This article also presents a structured approach for organizations to identify and …

In this Australian study, accreditation by regulatory organizations was associated with a positive safety culture, but was not associated with clinical performance.

This study describes the use of human factors engineering to improve the safety of spinal injections.

Although nearly one-third of deaths after bypass surgery were judged to be preventable based on retrospective review, preventable deaths were not correlated with individual hospital risk-adjusted mortality rates.

A prescribing tutorial for junior doctors successfully reduced medication prescribing errors in a children's hospital.

This study found no association between the number of information technology applications available in hospitals and improved risk-adjusted Patient Safety Indicator outcomes.

This study discovered that most surveyed hospitals had successfully adopted seven of nine medication-related safe practices and further characterized hospital culture and resource restraints as the primary barriers to wider implementation.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The authors describe the Partnership for …