Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.

Readmissions occur frequently after hospital discharge and may reflect opportunities to improve the quality and safety of care provided during the index admission. Using a modified Delphi process, an expert panel reviewed 30-day postoperative readmissions over a 7-year period for patients who had received surgery within the Veterans Affairs system. The study suggests that more than 50% of postoperative readmissions may be related to the quality of surgical care provided during the index admission.

Large-scale adverse events are those in which a group of patients are exposed to a risk of infection. Disclosure and notification of patients in such cases is complicated by the lack of relationship between the notifying clinician and patient. The Veterans Affairs (VA) medical centers examined patient utilization from administrative data following notification of a possible exposure to a bloodborne pathogen. Compared to reference patients, those notified of a possible exposure were more likely to be tested for bloodborne pathogens. African American patients were less likely to undergo blood testing for exposures compared to white patients, adding to concerns about disparities in patient safety. Those patients exposed to a large-scale adverse event during dental care were more likely to seek non-VA dental care in the short term, but most returned to the VA within 18 months of the exposure, suggesting some loss of trust that resolves over time.

This interview study examined how the Veterans Affairs medical centers disclosed large-scale adverse events to stakeholders. These incidents impacted multiple patients and included system failures as well as errors by individuals. Interviews with frontline staff, local leadership, and affected patients and family members examined strengths and weakness of the current disclosure process and elicited input for improvement. All stakeholders reinforced the need for tailored, interactive, multi-modal communication rather than standard mailed letters. While staff expressed the concern that adverse event disclosure led to loss of trust, patients and families stated that despite their initial distress they supported disclosure and follow-up care associated with large-scale adverse events. These findings are consistent with prior studies of error disclosure, but demonstrate a gap in frontline staff understanding of the rationale for disclosure.

The incidence and types of adverse events can vary widely across different clinical settings. This retrospective cohort study used a novel trigger tool to classify adverse events in the pediatric intensive care unit, with a particular focus on medication errors and patient-level risk factors for errors. The overall incidence of errors was similar to that found in prior studies, with surgical patients and intubated patients being most vulnerable to error. Medication errors were the most common type of error in this study, and prior research in the pediatric ICU setting has documented the benefit of computerized provider order entry for preventing medication prescribing errors, an example of which is discussed in an AHRQ WebM&M commentary.

This study demonstrated a 57% reduction in cardiac arrests following implementation of a physician-led rapid response system (RRS). The findings add to the existing literature by showing its potential value in the Veterans Affairs health care system.

Computerized provider order entry (CPOE) has been enthusiastically endorsed as a means of preventing medication errors, and some studies have shown clinical benefits associated with its use. However, a growing body of literature demonstrates that CPOE implementation may have many unintended consequences affecting clinician workflow, and these issues may account for the mixed safety performance of CPOE. This study, conducted at an academic tertiary care hospital, found that overall inpatient mortality decreased after CPOE was launched, with an estimated 36 lives saved in the first 18 months after implementation. These findings counter an earlier, widely cited study in which mortality increased after CPOE installation, and point to the importance of careful attention to the implementation process to ensure that CPOE meets its potential.

This study used in situ cardiopulmonary arrest simulation to prospectively discover potential safety hazards, which identified several opportunities for process improvement.

Despite existing controversy over their reported benefits, implementation and endorsement of rapid response teams (RRTs) remains widespread. This study demonstrated significant reductions in hospital-wide mortality and code rates after implementation of an RRT in a children's hospital. The team consisted of a critical care physician, nurse, respiratory therapist, and nursing supervisor. Generalizing the results from positive RRT outcome studies is often limited by methodological issues, such as defining clear triggers for activation and determining optimal composition of the RRT. A past study also demonstrated clinical outcome benefits, but used a physician assistant–led RRT. An accompanying editorial [link below] discusses these issues and the implications of this study for RRTs in pediatric inpatient care.

Three case reports provide context for improvement after implementing medical emergency teams at a Veterans Affairs health care facility. The authors found that the rapid response system allowed staff to identify a recurrent error and consequently remove an unsafe drug from the hospital's formulary.