This article reviews diagnostic errors occurring in neonatal intensive care units (NICUs), error causes and contributing factors, and prevention strategies. NICU diagnostic errors are relatively understudied but may have long-term consequences for health and development of infants.

… of patients' need for community-based services. … Williams H, Edwards A, Hibbert P, et al. Br J Gen Pract. 2015;65:e829-e837. …

Resilience is a characteristic that enables individuals to adapt to uncertain conditions in their work environment to prevent failure. Summarizing a workshop on how resilience can enhance patient safety, this commentary defines key elements of resilient organizations and provides examples of resilience engineering techniques applied in health care.

In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.

The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.

Antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE), are frequent sources of hospital-acquired infection (HAI) in the intensive care unit (ICU). Although the incidence of serious infections caused by MRSA has been decreasing, the optimal strategies to prevent spread of these bacteria remain unclear. In this cluster-randomized trial conducted in 18 ICUs, a protocol that involved universal surveillance and barrier precautions (gowns and gloves) for patients colonized with these bacteria was evaluated for effectiveness at preventing colonization and infection with MRSA or VRE. No reduction in colonization or infection was found, in part attributable to the fact that use of barrier precautions was suboptimal. Prior successful efforts to reduce HAI have emphasized the role of safety culture in addition to specific preventive interventions, an approach discussed in-depth in this analysis of the landmark Keystone ICU project.

This article provides practice and research recommendations to address patient safety issues in neonatal intensive care.

… medical records from 10 North Carolina hospitals over a 6-year period, using the Institute for Healthcare … remained unchanged. Recent research has also confirmed a persistently high rate of adverse events in Medicare and … of the state of the field, including a commentary by Dr. Robert Wachter and a plenary session at the National Patient …

… … Qual Saf Health Care … This systematic review identified a number of methods used for automated detection of safety …

This study found satisfactory reliability between internal and external reviewers using the IHI Global trigger tool to identify adverse hospital events.

This essay introduces three primary analysis techniques from industry that demonstrate effectiveness and utility in the health care setting.

… and safety. Investigators found no relationship between a hospital's quality status and its residents' curriculum or understanding of quality and safety. While a few programs had formal curricula, the majority of …

Medication errors are common in pediatric inpatients, but the best method of addressing them remains unclear. Studies of technological interventions, such as computerized provider order entry, have yielded inconsistent results. In this controlled trial, clinical pharmacists were deployed in the intensive care unit (ICU) and general medical and surgical wards in a pediatric hospital, and their effect on prevention of medication errors was assessed. Serious medication errors (including near misses) were significantly reduced in the ICU. No effect was seen on medication error rates for general ward patients, although the baseline rate of errors was much lower in those areas. A prior review documented the effectiveness of pharmacists at preventing medication errors in a variety of inpatient settings.

… prescriptions were at increased risk for suffering a preventable adverse drug event. Improved communication …

… The overall rate of preventable ADEs was similar to a prior outpatient study , but nearly three-quarters of …

… events (AEs), have been used to screen for errors in a variety of clinical settings . This AHRQ–funded study used methodology similar to a prior study in adult intensive care unit patients to develop a chart-based set of triggers for error identification in the …

… of medicine … N Engl J Med … The author argues that a systems approach  to hand hygiene is only useful if …

… study demonstrated that more than half of the patients in a single neonatal intensive care unit are at risk for …

This study found that medical errors often occur in patients with bronchiolitis, even more so in the critically ill.