… of health IT use on relationships among clinicians over a year-long period across three academic intensive care … awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls …

Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This review explores the role of safety culture and patient and family engagement in reducing opportunities for error in ICUs. The authors draw from quality improvement processes to provide insights for implementing safety initiatives and involving patients and families in these efforts.

This analysis of near misses in intensive care unit patients that were voluntarily reported by anesthesiologists found that the majority could be ascribed to one of five contributing factors, including a poor culture of safety and insufficient communication between teams.

Context has been identified as an important factor for successfully implementing patient safety improvements. This review highlights how ethnography can be used to identify and document factors that influence care delivery, including clinician behaviors and social relationships.

This review found that little is still understood about the processes, relationships, and organizational factors that influence interprofessional teamwork in intensive care units.

This article discusses the convergence of checklists, quality improvement research, and human test subject protection in the context of the Keystone ICU project.

This study describes medication error types that occur in “code” situations and also highlights their impact on other patients (referred to as “collateral damage errors” by the authors). Using data from MEDMARX, a voluntary reporting database that tracks medication information from participating hospitals, investigators evaluated more than 2000 code-related errors. Omission errors were the most common error type, registered nurses and respiratory therapists were most frequently involved (though also the most likely to prevent errors), and anti-asthma/bronchodilator medications were the most common therapeutic class implicated. The authors provide a number of anecdotes to illustrate the relationship of the errors to the code situation, and detail the level of harm and common contributing factors reported. Finally, a series of preventive strategies are offered to reduce code-related medication errors, including redundant staffing to prevent collateral damage errors, and the use of DNR identification systems and rapid response systems to reduce code frequency.