Opioid-related harm is a widely recognized patient safety concern. This study retrospectively examined critical care unit hospitalizations for opioid ingestions among children between 2004 and 2015. Over this period, hospitalizations for opioid ingestion increased dramatically, and nearly half led to critical care unit admission. Although the mortality rate for pediatric opioid ingestion was 1.6%, more than one-third of cases required mechanical ventilation. The authors call for stronger efforts to address the impact of the opioid epidemic on children. A previous PSNet interview discussed factors that contributed to the increase in opioid-related harm and strategies to address this growing patient safety concern.

Duty-hours restrictions have led to an increase in handoffs. This study compared handoffs delivered by overnight cross-covering residents to dedicated night-shift residents' handoffs. Investigators found no differences in information consistency across handoff types, which they conclude is reassuring evidence that limiting resident duty hours did not worsen handoff quality.

Introduction of a formal handoff system reduced technical errors and improved the quality of handoffs when transferring cardiac surgery patients from the operating room to the intensive care unit.

Creation of a dedicated pediatric cardiac surgery unit was felt to have clinical benefits, but many nurses reported feeling unable to provide safe care due to inadequate training or experience. The Bristol Royal Infirmary pediatric cardiology unit is considered a classic case of how a dysfunctional organization can result in dire clinical consequences.

This review analyzed whether medical school curricula and medical textbooks have fully addressed Institute of Medicine recommendations to improve patient safety education for physicians-in-training.