Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.

Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.

Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients.  Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

… J Nurs Educ … This thematic review of interventions targeting … reflective processing for nurses and nursing students. … Olsen JM, Aschenbrenner A, Merkel R, et al. A mixed-methods … review of interventions to address incivility in nursing. J Nurs Educ . 2020;59(6):319-326. Epub 2020/06/05. doi: …

Deviating from standard work processes has the potential to compromise safety. Using data from the Pediatric Emergency Care Applied Research Network, researchers analyzed incident reports determined to be process variance events. They found that 5.6% of events resulted in some form of temporary patient harm.

… Journal of digital imaging … J Digit Imaging … This innovative pilot study found …

Examining anesthesia safety in Europe following the recommendations outlined in the 2010 Helsinki Declaration, this review describes how checklists and an implementation toolkit contributed to progress and suggests areas requiring further work to achieve the document's goals.

Detailing how 22 pediatric emergency departments developed a process for sharing incident reports, this study describes the barriers that had to be overcome and the initial lessons learned from the project.

… Emergency medicine journal : EMJ … Emerg Med J … This study characterizes the types of medication errors …

This study conducted a retrospective chart review of more than 15,000 hospitalization records in 8 countries and found an adverse event rate range of 2.5% to 18.4% per country. Investigators estimated that more than 80% were preventable, suggesting a call to action for broader international efforts to promote patient safety.

The emergency interpretation of electrocardiograms in poisoned patients was frequently incorrect, increasing the potential for diagnostic error and incorrect management.