Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.

Clinicians must routinely triage and manage clinical issues over the telephone, but prior research has shown that this process is often error-prone. This simulation study of telephone triage in hospitalized patients found bidirectional problems with communication, as nurses frequently failed to provide crucial information and physicians did not take appropriate action even when properly informed.

The SBAR (situation, background, assessment, recommendation) communication tool has been implemented in an effort to improve nurse–physician communication, particularly by telephone. For this simulation study, 20 nurse–physician pairs were enrolled and the nurse in each pair was randomized to receive six written clinical scenarios to convey to the physician (three using the SBAR format, three in the usual format). Investigators found that relevant information was often not communicated by the nurse nor elicited by physicians, and use of SBAR did not improve communication.

This qualitative study reported the user, pump design problems, and lack of training as the most frequent factors attributed to adverse events with medical devices.

The investigators shadowed emergency department nurses and physicians and identified the types of interruptions that occurred and what factors contributed to them.

The researchers identified reasons for after-hours calls to physicians and suggest interventions to help nurses resolve common problems, reduce these calls, and improve communication.

The investigators analyzed operating manuals of five infusion pumps to evaluate their usability. The authors suggest that such manuals can be used to inform purchasing decisions when the actual device cannot be tested.

Using the concepts of "sharp" and "blunt" ends of practice, this article explores health professionals' differing opinions on biomedical device-related errors. Investigators requested that study participants express their views on events surrounding three true-error scenarios. Analysis of the transcribed responses revealed that interpretation varied widely between groups. While clinicians focused on clinical and human factors, biomedical engineers focused on device-related issues, and administrators emphasized documentation and training. The authors conclude that individual expertise largely mediates an error analysis, as no single interpretation provides a comprehensive view of all contributing factors.