Weight-based medication dosing is a common source of medication errors in children. This systematic review identified limited evidence that overweight and obese children maybe be at increased risk of weight-based medication dosing errors, but the authors note that the clinical significance is unknown.

The use of PRN (“as needed”) medications is a common source of medication errors. The authors describe the implementation of staff education and a pediatric intensive care unit (PICU) order set (with predefined PRN orders), which led to increased compliance with Joint Commission medication management standards. The related editorial discusses how investment in human factors and ergonomics can contribute to healthcare quality and safety improvements.

Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

Although transitions in care have been an active area of patient safety research, most of the focus has been on handoffs during hospitalization or the transition from acute to outpatient care. Exploring the literature on provider–provider communication at the time patients present to an emergency department or are admitted to the hospital, this systematic review found that few studies evaluate this issue and research on outcomes has been meager.

This tutorial offers a practical tool designed to allow frontline caregivers to turn formal safety culture assessment results into improvement strategies.

The authors discuss a project management tracking program to help promote a safety culture through sharing of stories and knowledge.