This study observed that neonates receiving opioids in the intensive care setting were at increased risk of a preventable adverse drug event. Implementation of a bar-code–assisted medication administration system reduced the risk of harm from opioid medication errors.

… by approximately 50% in this single-institution study. … Morriss FH Jr, Abramowitz PW, Nelson SP, et al. Effectiveness of a barcode medication …

The vast majority of medication errors among geriatric patients at a university hospital were preventable. Factors predicting medication errors included patient factors, medication factors (i.e., polypharmacy), and systems factors (i.e., nurse staffing changes).

Past research suggests a relationship between nursing workload and quality of care in hospitalized patients. This study examined the relationship between hospital workload and adverse events and discovered that a hospital operating consistently near capacity had increased rates of adverse events. Investigators reviewed more than 6800 patient charts at four different teaching hospitals and found workload effects at only one of the sites. At this site, they estimated that a 10% increase in occupancy led to a 15% increase in adverse events. The authors suggest that consistently high workloads, where patient to nurse ratios may increase, pose a risk to patient safety.

This prospective, randomized time series trial examined the impact of smart pumps with integrated decision support on adverse medication events. Investigators used a decision support system that allowed categorization of noted events by type, preventability, and severity. Despite finding similar serious medication error rates in both study groups, opportunities for intervention were discovered through improved detection with the new technology. The authors concluded that improved infusion safety can result from incorporating novel technology but stressed that behavioral and educational factors of users must be considered.

This study applied a checklist to address 12 commonly identified operating room crises, and found that the tool led to significant improvements in adherence for critical management steps.