Alarm fatigue can lead to distraction and diminish safe care. Based on findings from their Patient Safety Learning Laboratory, the authors used human factors engineering to develop a classification system to organize, prioritize, and discriminate alarm sounds in order to reduce nurse response times.

This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.

Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.

Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.

Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.

… Quality … Am J Med Qual … Crew resource management (CRM), a type of team training , is a prime example of an aviation strategy often applied to … three hospitals. After the training, investigators found a significant, consistent improvement across multiple domains …

… and care teams . This commentary examines habit as a mechanism to ensure that high performance practices are …

This ethnographic study explored the underlying reasons for safety and communication problems at the transition of care between the emergency department and hospital wards. Through observation and interviews with physicians and hospital leadership, the study identifies structural and cultural barriers to effective communication and reveals time-consuming workarounds that physicians utilized to ensure patient safety.

Handoffs transfer accountability for a patient from one clinician to another. This commentary proposes a framework for transfers from the emergency department to other units within the hospital that highlights environmental, organizational, and social factors that affect these interactions to augment handover quality.

Communication failures at the time of patient handoffs have been frequently implicated in adverse events. Comparing how narrative modes of communication such as storytelling and structured tools like checklists can be utilized to augment information transfers in health care, this commentary advocates for more research into strategies to improve narrative thinking.

Researchers performed direct observation of nurse and physician handoff communication to assess their use of interactive questioning, a recommended aspect of this approach. Experienced providers utilized more interactive questioning, and physicians used interactive questioning more often than nurses. These results suggest that providers acquire handoff skills over time and that such techniques may be needed in education for less experienced providers.

Discussing how noise and communication failures in the emergency department affect patients and clinicians, this commentary recommends tactics to enhance communication and reduce ambient noise in this setting.

This commentary describes human factors, usability, and informatics recommendations for electronic health records in pediatrics to improve their usefulness and reduce the risk of errors.

This commentary discusses the importance of handoff communication in ensuring safe transfers and recommends that mental models be developed within the care team to improve handoff safety.

… attempting to retrospectively analyze adverse events is a well-documented problem in the safety literature. This …

This review highlights gaps in the current literature on handoffs, which include inadequate research supporting best practices in the context of growing mandates to do so.

… the seven primary functions of handoffs with each tied to a set of different interventions for improvement. The … the lack of consensus about the primary purpose of a handoff, and that the definition should avoid an overly … challenges in developing handoff improvement strategies. A past AHRQ WebM&M commentary discussed a case of a handoff …

Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.

… : JAMIA … J Am Med Inform Assoc … This study found that a patient handoff tool can reliably extract information from … additional opportunities for improvement were identified. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a …