Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive model assessing nurses’ willingness to report medication near-misses. On a scale from 0 to 3 (where high scores indicate more willingness to report) the mean score of nurses’ willingness to report near-miss incidents was 1.79. The model predicted a 19% variance in willingness to report. The strongest predictors of willingness to report were non-punitive safety climate, transformational leadership, trusting relationships with nurse managers, and familiarity with the reporting system. The authors conclude that social and system factors are necessary to improve nurses’ voluntary reporting of medication near-misses.

… inhibits their work in this area. … Monsees E, Goldman J, Vogelsmeier A, Popejoy L. Nurses as antimicrobial stewards: …

This AHRQ-funded analysis of patient safety research found that research output—as measured by federal grant funding and peer-reviewed publications—increased sharply between 1995 and 2014. Publication of the To Err Is Human report and passage of federal budget stimulus funds were associated with an increase in patient safety publications and research funding.

Situation awareness in teams contributes to their reliability. Examining tools to monitor situation awareness among nurses, this review determined that measures to track this safety behavior are lacking. A WebM&M commentary discussed situation awareness and patient safety.

Focus groups with physicians, nurses, and pharmacists revealed that each profession had a distinct view of the purpose of and optimal process for medication reconciliation.

Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.

Nursing leadership that facilitated a culture of safety achieved improvements in medication error rates, in this study comparing two Midwestern nursing homes.

This article reports on a Missouri effort to train health care leaders in the foundations of just culture.

Electronic medication administration records (eMARs) are one technology solution being applied to reduce the potential for medication errors. This AHRQ-funded study provides detailed descriptions and learnings from a quality improvement effort to implement eMARs in five nursing home facilities.

This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.