… decreased with no increase in maternal complications. … Kern-Goldberger AR,  AR, Nicholls EM, Plastino N, et al. The …

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

… 1,000 patient days. … Dykes PC,  Curtin-Bowen M, Lipsitz S, et al. Cost of inpatient falls and cost-benefit analysis …

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.

Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.

… but not signed), which needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to improve problem list …

… antibiotics and opioid and non-opioid analgesics. … Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-patient orders in …

… a culture of safety, and continuous analysis of errors. … Adelman JS, Gandhi TK. COVID-19 and patient safety: time to …

… reduction in falls with injuries. … Dykes  PC, Burns Z, Adelman J, et al. Evaluation of a patient-centered …

Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  

This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.

Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.

The Fall TIPS (Tailoring Interventions for Patient Safety) program has been shown to be effective in preventing inpatient falls through formal risk assessment and tailored patient care plans. This study demonstrated that patients with access to the Fall TIPS program are more engaged and feel more confident in their ability to prevent falls than those who were not exposed to the program.

… practices for heart failure patients. … Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart …

… or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced …

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

… a paper version, and a version displayed on the patient's bedside monitor. All three methods were effective. …

Opening multiple patients' charts in the electronic medical record simultaneously may increase the risk of wrong-patient orders, a known patient safety hazard. Researchers analyzed intercepted wrong-patient medication orders in an emergency department over a 6-year period and found no significant reduction when the maximum number of charts allowed to be open at the same time decreased from 4 to 2. Similarly, there was no significant increase when the maximum number of charts permitted to be open simultaneously increased from 2 to 4.