Patients in long-term or residential care facilities are at high risk of falls. In this study, researchers applied the International Classification for Patient Safety (ICPS) criteria to categorize types of falls occurring in residential aged care facilities in Australia. Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas. Resident pre-existing psychological or physical health were the most common contributing factor in falls that required a hospitalization.

Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.

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.

The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.

Medication errors are a common cause of preventable harm in long-term care facilities. This systematic review explored how residents and families engage in medication management in aged care facilities. Factors hindering effective engagement included insufficient communication between residents, families, and providers; families’ hesitation about decision making; and lack of provider training.

… and involvement of the pharmacist . … Manias E, Bucknall T, Woodward-Kron R, et al. Interprofessional and …

Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.

Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.

… about the benefits compared to single-checking. … Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking …

This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  

Medication administration errors are common and account for a significant fraction of medication errors. This systematic review examined the effect of medication double-checks on medication administration errors. Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence to double-checking protocols. Only one high-quality study showed improvement in medication administration error rates when a double-check took place. No studies demonstrated differences in patient harm with double-checking compared to usual medication administration practice. The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking medication administration confers a meaningful safety benefit. A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy for verifying the order prior to administration, which led to a medication administration error.

Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, including managing changes to their medications. This systematic review suggests that there is significant opportunity for health care providers to improve family engagement in managing medications of elderly patients during care transitions.

Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.

This review examined whether use of health information technology could improve physician awareness of actionable test results and follow-up of test results. The included studies were of variable quality, and though some did demonstrate improvement in test result management using health information technology, there was no consistent effect. The authors conclude that health information technology alone is not sufficient to close safety gaps in test result management.

Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.

This meta-analysis examined the role of computerized provider order entry (CPOE) in preventing pediatric dosing errors. Combining the results of 9 studies, researchers estimate that about 5% of pediatric inpatient medication orders contain a dosing error, but it is unclear whether CPOE reduces pediatric dosing errors. The authors call for further studies with controlled designs to determine the effectiveness of CPOE on improving pediatric medication dosing.

Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.

Rapid response teams are well established in adult and pediatric hospitals. As part of efforts to increase patient engagement in safety efforts, some hospitals allow patients to summon the team directly. This qualitative study of patients and caregivers at two Australian hospitals identified significant barriers to family-activated rapid response teams. Principally, patients did not feel they had the knowledge to make a clinical decision regarding their care and expressed concern about overriding the clinical staff's decisions.

This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.