… care workers noted that the lack of necessary resources (e.g., PPE, testing) and insufficient guidance specific to home … conditions feel unsafe. … Osei-Poku GK, Szczerepa O, Potter AA, et al. Safety trade-offs in home care during …

Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.

Medication-related adverse events resulting in hospital admission were three times as common among older adults with dementia compared to older patients with intact cognition. A WebM&M commentary discussed an incident involving an elderly patient who experienced an adverse drug event requiring hospital readmission.

Incident reporting is widely utilized to detect adverse events and near misses, but underreporting remains a problem. This study describes a quality improvement initiative to increase event reporting across a pediatric health care system.

Polypharmacy in older patients is a predictor of medication errors. However, deprescribing—stopping or reducing medicines in a patient's drug regimen—can introduce opportunities for harm if not done appropriately. This commentary presents a protocol to enhance the safety of deprescribing by considering the medication therapy needs of each individual patient.

This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the Armstrong Institute for Patient Safety and Quality. The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff members, 140 core faculty, and an annual budget of about $15 million. The new governance structure includes oversight from a patient safety and quality board committee. The overall goal of these efforts was to achieve quality metrics that would meet the requirements for the Delmarva Foundation Excellence awards and The Joint Commission's Top Performer award at each of the 5 Johns Hopkins hospitals (2 academic and 3 community institutions). By 2013, the health system reached at least 96% compliance on 6 of 7 targeted measures, with 4 hospitals receiving the Delmarva Foundation award and 2 hospitals garnering the Joint Commission award, making a strong case for the effectiveness of this robust high-reliability strategy.

… also called the utility of Beers criteria into question. … Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. …

This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.

The authors of this AHRQ-funded study applied techniques from human factors engineering and observational research to analyze interruptions in the cognitive work of nurses. They found that most interruptions took place during the medication preparation process.

Using a designated criteria system for inappropriate medication prescribing, this study examined the impact of such prescriptions on hospitalization and death. Studying more than 3300 nursing home residents, investigators reported greater odds of being hospitalized in the month following an inappropriate prescription, an associated greater risk of death, and similar risk with even intermittent exposure to such prescriptions. The authors conclude that their reported associations call for improved attention and education for providers who prescribe medications to the elderly.