This pre–post study found that medication administration errors decreased after the introduction of barcode medication administration, echoing prior studies. The authors conclude that use of barcode medication administration technology improves patient safety by reducing medication errors.

… . This retrospective cohort study assessed the impact of a 2016 Massachusetts law that mandated minimum nursing ratios … care, which authors argue cannot be simply defined with a staffing ratio. A PSNet perspective and a WebM&M commentary further explore the safety risks of missed …

… Annals of surgery … Ann Surg … Opioid-related mortality is a patient safety concern. Prior studies have demonstrated …

… Surgery … JAMA Surg … Review of malpractice litigation is a longstanding method for identifying patient safety vulnerabilities. Investigators reviewed a legal database for malpractice cases involving surgical … than half of cases implicated inadequate supervision as a contributing cause. As with previous research on closed …

… access is critical to timely and accurate diagnosis. A recent WebM&M commentary discussed how cognition can influence diagnostic …

… with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and …

Surgical site infections are an important type of health care–associated infection that safety efforts aim to prevent. This case-control study compared patients matched on age, gender, and elective procedure who developed surgical site infections with those who did not. Although investigators hypothesized that having additional personnel in the operating room would lead to higher likelihood of infection, after adjusting for patient- and procedure-related factors, they found this was not the case.

… and patient characteristics, transferred patients had a higher risk of death compared with patients admitted …

Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.

… and surgical outcomes over time. This study examined 3 and a half years of data from the University HealthSystem Consortium, which represents a large cohort of academic medical centers. …

Although effectiveness of rapid response teams has traditionally been measured by using rates of cardiac arrests or intensive care unit transfers, this study advocates for using the AHRQ failure to rescue metric instead. Failure to rescue rates declined in the second year after implementation of the rapid response team in concert with increased utilization of the team.

This study used screening of administrative data to determine the overall probability of an individual patient experiencing an adverse event during hospitalization.

This systematic review found seven different definitions of preventable harm used in the patient safety literature, but none were considered to be more valid or reliable than the others.

… … Am J Med Qual … The epidemiology of adverse events on a population basis has been well studied, but how these data … been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring … ill patient with multiple underlying comorbidities. … Naessens JM, Campbell CR, Shah N, et al. Effect of illness …

This study found that the Patient Safety Indicators lacked sensitivity and specificity for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program adverse event detection methodology.

This study implemented a data-matrix–coded sponge system that eliminated retained sponges while causing no significant disruption in operating time or workflow.

… Ill. : 1960) … Arch Surg … Wrong-site surgeries are a rare yet devastating complication for patients. Despite … , these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on … the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a …

… that patients who were given follow-up appointments (at a mean of 6 days after discharge) were just as likely to be …

… results. For instance, only 6.2% of hospitalizations with a PSI also had a provider-reported event, and only 10.5% of … public reporting and performance comparisons. An AHRQ WebM&M commentary discusses the limitations of using PSIs for …