Antimicrobial stewardship is an important element of patient safety. This scoping review explored how antimicrobial indication documentation can impact antibiotic use and clinical outcomes. The authors conclude that this is a growing area of research interest and note that emerging evidence indicates that appropriate antimicrobial indication documentation can improve prescribing and patient outcomes but that larger trials are needed to provide more robust evidence.

Research has established that disclosure of medical errors to patients and families is essential for maintaining a therapeutic alliance. However, less is known about what patients and families may expect regarding the disclosure of near misses. In this interview study, parents of hospitalized children expressed varying preferences surrounding disclosure of errors, near misses, and the degree to which they desired their children participate in the disclosure process.

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

Inappropriate antibiotic use contributes to microbial resistance for the recipient and the community. This study found increased harms related to antibiotic use among older patients living in nursing homes with higher antibiotic use compared to nursing homes with overall lower antibiotic use. These findings demonstrate the need to manage antibiotics effectively to improve the safety of all nursing home residents.

There is a consensus in the safety field that organizations must use multiple methods of detecting errors and adverse events, as individual approaches vary in their ability to identify different types of safety issues. Rapid response systems (RRSs) have been widely deployed to detect and stabilize deteriorating hospitalized patients, and this study investigated whether analysis of RRS activations could be used to identify preventable hazards. Systematic review of patients seen by the RRS revealed that almost 20% had experienced an adverse event, 80% of these were preventable, and most were not reported to the institution's incident reporting system. Hospitals should consider formal review of RRS activation as a trigger for identifying adverse events.

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.

This systematic review attempted to quantify the excess attributable cost of patient safety events in hospital care but found considerable methodologic weaknesses in the available literature addressing this question.

Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.

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.