Tablet-splitting may introduce patient safety risks, such as unpredictable dosing. This systematic review and qualitative synthesis did not identify substantive evidence to support tablet-splitting concerns, with the exception of sustained-release tablets and use by older adults who may struggle to split tablets due to physical limitations.

Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.

Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.

… J Patient Saf … In this survey of clerkship directors in …

Negative consequences can radiate throughout an organization after a patient harm event. This commentary provides an overview of first victims, second victims, and third victims of medical errors, then elaborates on how patient safety professionals responsible for investigating adverse incidents and designing improvements can experience emotional stress, bullying, and staff turnover. The authors recommend increased support and measurement of the impact of patient safety events on these individuals.

This usability study examined whether older adults could use a mobile application to consider the risks and benefits of anticholinergics, a high-risk medication class. The 23 participants reported an overall high usability for the application, suggesting that mobile health information technology has potential to engage patients in safety.

Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.

… concepts: configuration, engagement, and adaptation. … Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human …

This commentary describes a model that combines work system and process redesign to promote human factors engineering as a patient safety improvement strategy.

More complex treatments and increased provider workload were associated with errors in palliative radiation treatment.

Pediatric nurses reported frequently violating medication administration policies, especially in emergency situations. The impact of these protocol violations on patient safety was unclear.

… Journal of patient safety … J Patient Saf … This qualitative study identifies user, …