Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.

Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.

This qualitative analysis of verbal handoffs within physician dyads and within nurse dyads found that most questions during handoffs came from incoming providers, who were typically requesting additional information or seeking consensus on clinical reasoning. These results complement a recent study that also supported adding interactive questioning to structured handoff communication.

This qualitative analysis found that anticipatory management conversation occurred in most physician-to-physician and nurse-to-nurse verbal handoffs. The authors suggest that structured handoffs should be supplemented with additional verbal communication regarding relevant contextual information.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … This ethnographic study used direct …

This study used qualitative techniques to identify essential components of safe and effective patient handoffs between nurses.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … This study found that a patient …

Medical students received training in a modified SBAR (situation-background-assessment-recommendation) communication method, resulting in improvement in their ability to clearly communicate with senior colleagues in a simulated setting.

This review details the background of a methodology aimed to record specific behaviors, rather than opinions or estimates, in evaluating a given activity. The author describes the development of the "critical incident technique," the history of its evolution dating back to World War II, and its success in analyzing processes during those times. Further discussion outlines the steps involved in applying the technique and how this systematic process provides data that leads to effective solutions. Case examples are included to illustrate the mechanics of the technique, in the context of creating a foundation for such procedures in psychology. The technique has been adopted and applied to health care, specifically in studying anesthesia mishaps. Interested users can review a bibliography that chronicles its development and use as a research method.