Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.

Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.

… identified flaws in handoff practices; then they designed a standardized handoff process to address these … could be applied to other patient safety processes. A past PSNet interview discussed the application of human …

… Surg … This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ … teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this …

… of participants, identified several latent errors in a hospital's emergency response system. Dr. David Gaba, a pioneer in simulation in health care, was interviewed for …

… Analg … This commentary describes lessons learned from a multidisciplinary initiative developed to enhance safety of …

This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

This study found significant differences in the types and severity of intensive care unit medication errors between hospitals in the United Kingdom and the United States.

This commentary discusses concerns associated with patient transfers from the operating room to the intensive care unit and describes strategies to improve such handoffs, including standardizing processes and offering training to enhance teamwork and communication.

This review summarizes how standardizing processes, completing urgent clinical tasks prior to information transfer, allowing patient-specific discussion during verbal handovers, and providing training in team and communication skills would improve patient handovers.

To detect and analyze errors, health care has traditionally relied on retrospective methods such as incident reporting and root cause analysis. This commentary draws a contrast between this approach and that used in the nuclear power industry, which focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power facilities can request peer review by an independent non-regulatory body, which conducts a detailed safety assessment and makes specific recommendations for safety improvement. The authors recommend developing a similar process for hospitals and discuss barriers that would need to be overcome in order to implement such a process.