A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.

Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.

Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.

Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.

… can integrate into local practice to improve safe care. … Redley B,  Douglas T, Hoon L, et al. Nursing guidelines for …

… adverse drug events, and functional decline. … Mekonnen AB, Redley B, de Courten B, et al. Potentially inappropriate …

This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

… patients to alert practitioners to concerns). … Newman B, Joseph K, Chauhan A, et al. Do patient engagement …

… about decision making; and lack of provider training. … Manias E, Bucknall T, Hutchinson A, et al. Resident and …

Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.

Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.

In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.

… medications of elderly patients during care transitions. … Manias E, Bucknall T, Hughes C, Jorm C, Woodward-Kron R. …

Researchers conducted eight focus groups to understand how to better engage Ethiopian hospital pharmacists in medication safety. Most expressed enthusiasm about having an active role in safety as long as concerns related to space, resources, and training were addressed. A recent PSNet perspective examined team-based approaches to improving safety during hospital discharge.

Communication failures hinder safety of health care delivery and are particularly prevalent in medication errors. This review explores how interdisciplinary work can augment communication during medication processes and highlights interdisciplinary collaboration strategies such as pharmacist engagement in care teams.

Interruptions in nursing care are common and can contribute to errors. In keeping with prior research, this observational study of nurses found that interruptions in medication preparation and administration can compromise patient safety.

Standardized screening tools are frequently used to assess risk among hospitalized older patients to prevent harm from falls and adverse drug events. This mixed methods study of 11 health services across Victoria, Australia, found that skin integrity and fall risk were consistently assessed, but there was significant variability across institutions with regard to the assessment of nutrition, cognitive function, and medication issues.

This study elicited patients' reports of adverse events during hospitalization. Researchers found that 7% of hospitalized patients reported experiencing an adverse event and, consistent with prior studies, patients contributed unique contextual data to adverse event reporting.

Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.