The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

Heuristics provide cognitive shortcuts in the face of complex situations, and thus serve an important purpose. This survey of pediatricians found that identification of diagnostic heuristics was limited. Most respondents expressed discomfort discussing diagnostic errors in public settings, citing fear regarding loss of reputation.

Pediatric patients are particularly vulnerable to medication errors. This review explores efforts to reduce risks of medication mistakes in this patient population and safety improvement strategies such as smart pumps, barcoding systems, and workflow management systems.

The Joint Commission requires hospitals to have antimicrobial stewardship programs to prevent harm from antimicrobial overuse. The authors interviewed antimicrobial stewardship program leaders to delineate the qualities of successful programs and future directions for the field. A past WebM&M commentary described the harms associated with inappropriate antibiotic use.

Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk for adverse drug events. Health information exchange can enhance medication safety through improved access to prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted to a single hospital in the intervention arm and without such information access for patients in the control arm. In the first 10 months of the study, the health information exchange provided access to prescribing information from large hospitals and a pharmacy insurance plan, but only hospital prescribing information was available during the last 21 months because the insurance plan began charging for data. Although researchers found no significant difference between the intervention and control groups with regard to the number of medication discrepancies, patients who underwent medication reconciliation with access to pharmacy insurance data had a higher number of medication discrepancies identified than control patients. They conclude that charging for pharmacy data interrupted the positive effect of health information exchange on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing information led to an adverse drug event.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.

Health information technology (IT) has had a profound impact on health care. Although health IT has led to efficiency gains and improved safety, unintended consequences remain a concern. In this systematic review, researchers analyzed 69 studies from 2001 through 2012 that examined the use of health IT in a clinical setting and its effect on safety outcomes for patients. About one-third of the studies demonstrated a positive impact of health IT on patient safety outcomes, but many of these focused on the hospital setting, involved a single institution, and looked at decision support or computerized provider order entry. The authors suggest that future studies should focus on other areas in which the impact of health IT remains understudied, such as in outpatient and long-term care settings, and they underscore the need for higher quality research. A recent WebM&M commentary described the unintended consequences of health IT.

Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.

Computerized provider order entry (CPOE) reduces overall medication error rates, but this effect may depend on effective clinical decision support systems (CDSS). Whereas most previous longitudinal studies of outpatient CPOE have been performed in academic settings, this study examined community-based primary care providers, who actually write the bulk of ambulatory prescriptions. Rates of prescribing errors immediately following CPOE implementation were low, with approximately 6 errors per 100 prescriptions. These rates were sustained at 1 year following implementation. A previous AHRQ WebM&M perspective described the importance of thoughtful application of CDSS for medication prescribing.

A standardized handoff protocol for cardiac surgery patients between the operating room and intensive care unit led to decreases in unplanned extubations and the amount of time spent on ventilators.

Many institutions are now moving from relatively unsophisticated electronic health records (EHRs) to more advanced systems. This transition can pose safety hazards; a previous article demonstrated that replacing an older EHR with a new system resulted in a higher incidence of some types of prescribing errors. However, this follow-up study found that prescribing errors consistently decreased as users became more familiar with the new system and as the system was refined. Prior studies have also shown that at least 1 year of use is required to obtain the safety benefits of EHRs. The article provides an excellent example of the ongoing monitoring and adaptation required to effectively implement EHRs.

In this study, better safety climates in emergency departments were associated with more intercepted near misses but not with fewer preventable adverse events.

This study implemented an order verification screen, including the patient's photograph, to reduce the risk that orders will be placed in an unintended patient's electronic health record. In a limited analysis, it appeared to be effective.

Pediatric nurses reported frequently violating medication administration policies, especially in emergency situations. The impact of these protocol violations on patient safety was unclear.

This commentary presents a model developed to explore how health information technology affects care delivery.

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

The implementation of new computerized provider order entry (CPOE) systems can have unintended consequences, including adverse clinical outcomes. As CPOE systems evolve, health systems are beginning to transition from older versions (with only limited decision support capabilities) to more sophisticated systems. This analysis of a primary care practice that underwent such a transition found fewer overall prescribing errors with a newer system. However, this improvement was largely due to the new system's ability to prevent "do-not-use" abbreviations in prescriptions; the incidence of other types of prescribing errors actually increased for the first 3 months after implementation. Even with experienced CPOE users, novel systems evidently have the potential to adversely affect patient safety.