This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.

Leaders of quality improvement/patient safety and continuing education in Canada felt that efforts in these two domains were separated and that there were many opportunities to collaborate. However, they had differing views on how to best integrate programs.

This prospective error investigation study combined a trigger approach to identify possible adverse events with medical record review and structured interviews to determine underlying causes for adverse events. Investigators found that a myriad of factors contribute to adverse events, and multiple distinct interventions would be needed to prevent the detected events. The authors advocate for a framework to classify underlying causes together when they can be addressed by the same intervention.

This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.

This study used interviews with academic faculty—who had developed curricula in patient safety and quality improvement—to identify aspects of the cultural milieu that act as facilitators and barriers to embedding safety principles into medical training.

This commentary describes a medication reconciliation improvement toolkit, along with results and lessons learned from implementing the strategy.

This narrative review proposes an approach that integrates concepts from continuing education, knowledge translation, patient safety, and quality improvement to promote collaboration in interdisciplinary health care improvement work.

The effect of electronic medical records and computerized provider order entry (CPOE) on medical education is unclear. This qualitative study identified five areas in which CPOE could positively or negatively affect the educational process.

Progress has been achieved in several areas of patient safety, but the cost-effectiveness of successful interventions remains an important question for policymakers and organizational leadership. This systematic review evaluated the cost-effectiveness of interventions to address 15 key safety targets (including health care–associated infections, adverse drug events, retained foreign bodies after surgery, and wrong-site surgery), but identified only 7 methodologically adequate economic analyses. Based on this limited dataset, the authors identified 4 cost-effective safety interventions, including checklists to prevent catheter-related bloodstream infections and medication reconciliation conducted by pharmacists. More robust economic analyses will be required in order to help prioritize safety interventions in the future.

This study redesigned a hospital's paging process to reduce pages sent to the wrong physician by adopting team-based paging practices.

This study underscores the importance of heuristic evaluations in the design, selection, and implementation of computerized provider order entry systems.

In this study, clinicians were notified in real time about critical lab test abnormalities and provided with immediate decision support. However, this intervention did not prevent adverse events attributable to the critical test results, nor did it seem to result in more timely management.

A user-centered design format for computerized provider order entry order sets proved to be more efficient and usable than standard formats, with no difference in prescribing error rates.

A recent report by the National Patient Safety Foundation called for medical schools and residency programs to reengineer their curricula to emphasize patient safety and quality improvement (QI) concepts. This systematic review evaluated the published literature on existing safety and QI curricula, and found that curricula were generally popular among trainees and resulted in increased knowledge of safety or QI concepts. Curricula focused on teaching systems analysis and continuous quality improvement principles, and some studies did find improvement in care processes associated with the educational intervention.

Communication in the hospital setting is critical to safe patient care. This study discovered that 14% of text pages were sent to the wrong physician, with nearly 50% of them requiring emergent or urgent attention.

Significant attention to gaps in the continuity of care has led to past research focused on hospital transitions and medication management systems in the ambulatory setting. This study tracked information exchange between outpatient providers caring for the same patient following hospital discharge. Remarkably, they discovered that information from the previous visit was available at a subsequent visit only 22% of the time. Factors associated with information being available included care by a family physician and whether that physician was treating the patient prior to hospitalization. The findings raise ongoing concerns about poor communication and highlight the need for systems to foster more effective clinical information exchange between providers. A past AHRQ WebM&M perspective discussed care transitions associated with hospital discharge.

Although nearly one-third of deaths after bypass surgery were judged to be preventable based on retrospective review, preventable deaths were not correlated with individual hospital risk-adjusted mortality rates.

Barcoding technology is recognized as a mechanism to prevent adverse drug events, but unintended consequences and workarounds have been reported after implementation. Early success with the technology also prompted its use to prevent retained surgical instruments and errors in blood transfusion, expanding on the potential for its application. This commentary discusses the background of barcoding for medication administration, reviews current experiences and benefits, and also outlines the downsides and costs. The authors do point out that, like most technologies, barcoding may lead to new problems, and careful evaluation of such systems is required. They conclude with a series of recommendations, including requirements for drug manufacturers to offer all medications in single-unit doses with barcode labeling, and legislative flexibility to keep up with evolving technologies.

This prospective study compared admitting prescription medication orders with a comprehensive medication history obtained through interview. Investigators aimed to evaluate the differences between the two sets of medication lists to demonstrate the number of discrepancies. Results demonstrated that more than half of the study participants had at least one unintended discrepancy. The most common errors included ones of omission, and the majority of the errors led to no significant harm but some discomfort or clinical deterioration. The authors discuss the potential for intervention to reduce these types of medication errors and the role of pharmacists in assisting with accurate medication histories.