This commentary describes the establishment of the Center for Professionalism and Peer Support at Brigham and Women's Hospital in Boston. The initiative aims to bolster safety culture by teaching professionalism, managing error disclosure, supporting wellness, and providing a program for second victims. The intervention has worked to remediate unprofessional behavior in more than 200 cases, suggesting that a structured and staffed initiative can support the development of a safety culture. An accompanying editorial outlines five critical aspects of the program: leadership commitment, institutional champions, non-punitive reporting, a structured intervention model, and shared understanding of definitions, policies and procedures, and goals. A prior AHRQ WebM&M commentary also discusses the role of professionalism in safety.

Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.

Discussing safe care in the context of both systems failures and individual responsibility, this commentary advocates for directly addressing disruptive and impaired physician behaviors.

… Journal of vascular surgery … J Vasc Surg … The author discusses disruptive, …

Bar code technology has been widely recommended to reduce adverse drug events (ADEs) by ensuring the correct medication and dose are dispensed, but prior research has pointed out potential unintended consequences of its use. This AHRQ–funded study measured the incidence of drug dispensing errors and potential ADEs before and after implementation of bar code–assisted dispensing at an academic hospital. Both types of errors were significantly reduced when each dose of medication was scanned, but potential ADEs were increased in a configuration requiring scanning of only one dose per batch. The authors conclude that bar coding systems should be configured to mandate scanning of each dose at least once during the dispensing process.

… Annals of surgery … Ann Surg … In this panel discussion from the 2005 …

… Walk Rounds™ . The discussion emphasizes the need for an action-oriented approach in utilizing such information …