Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.

This before-and-after study demonstrated that implementing a standardized handoff process called I-PASS between the operating room and the postanesthesia care unit led to improved information transfer, as measured by direct observation, and increased nurse satisfaction with the handoff without adding to the duration of the process. These results contribute to the evidence for standardization of work, a concept drawn from human factors engineering, to support safe medical care.

This commentary describes how an evidence review program that engaged frontline nurses in implementing practice changes improved collaboration, competence, autonomy, and professional development.

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.