Reporting incidents and errors is a cornerstone of patient safety improvement efforts, but challenges remain, including low quality of reports and low rates of reporting. This article discusses the technological challenges of incident reporting and offers recommendations to improve usability in future reporting systems.

Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive model assessing nurses’ willingness to report medication near-misses. On a scale from 0 to 3 (where high scores indicate more willingness to report) the mean score of nurses’ willingness to report near-miss incidents was 1.79. The model predicted a 19% variance in willingness to report. The strongest predictors of willingness to report were non-punitive safety climate, transformational leadership, trusting relationships with nurse managers, and familiarity with the reporting system. The authors conclude that social and system factors are necessary to improve nurses’ voluntary reporting of medication near-misses.

… inhibits their work in this area. … Monsees E, Goldman J, Vogelsmeier A, Popejoy L. Nurses as antimicrobial stewards: …

This AHRQ-funded analysis of patient safety research found that research output—as measured by federal grant funding and peer-reviewed publications—increased sharply between 1995 and 2014. Publication of the To Err Is Human report and passage of federal budget stimulus funds were associated with an increase in patient safety publications and research funding.

Despite many technological innovations, safety events occur frequently in critical care settings. This observational study of critical care rounds found that more safety events occurred when technology such as computer alerts, phones, and pagers interrupted physicians. A previous WebM&M commentary discussed an incident involving a technology interruption that led to serious patient harm.

… problems as well as user interface design issues. … Kang H, Wang J, Yao B, et al. Toward safer health care: a review …

An extensive body of literature documents the unintended consequences of information technology in the inpatient setting. This qualitative study identifies many similar unintended consequences after introduction of electronic health records into Australian nursing homes.

Focus groups with physicians, nurses, and pharmacists revealed that each profession had a distinct view of the purpose of and optimal process for medication reconciliation.

This retrospective study found that nearly one quarter of incident reports lacked sufficient information to accurately classify and analyze the incident.

Nursing leadership that facilitated a culture of safety achieved improvements in medication error rates, in this study comparing two Midwestern nursing homes.

This article reports on a Missouri effort to train health care leaders in the foundations of just culture.

Electronic medication administration records (eMARs) are one technology solution being applied to reduce the potential for medication errors. This AHRQ-funded study provides detailed descriptions and learnings from a quality improvement effort to implement eMARs in five nursing home facilities.

This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.