Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.

Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.

Optimal use of health information exchange approaches such as event notification systems may be influenced by organizational capabilities. This study found that healthcare organizations whose positive perceptions of event alerts fit within existing workflows were more likely to use event notification services to improve care coordination and care quality.

Pediatric patients are particularly vulnerable to medication errors. This review explores efforts to reduce risks of medication mistakes in this patient population and safety improvement strategies such as smart pumps, barcoding systems, and workflow management systems.

… programs and future directions for the field. A past WebM&M commentary described the harms associated with …

… on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing …

Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.

… the need for higher quality research. A recent WebM&M commentary described the unintended consequences of health …

Computerized provider order entry (CPOE) reduces overall medication error rates, but this effect may depend on effective clinical decision support systems (CDSS). Whereas most previous longitudinal studies of outpatient CPOE have been performed in academic settings, this study examined community-based primary care providers, who actually write the bulk of ambulatory prescriptions. Rates of prescribing errors immediately following CPOE implementation were low, with approximately 6 errors per 100 prescriptions. These rates were sustained at 1 year following implementation. A previous AHRQ WebM&M perspective described the importance of thoughtful application of CDSS for medication prescribing.

Many institutions are now moving from relatively unsophisticated electronic health records (EHRs) to more advanced systems. This transition can pose safety hazards; a previous article demonstrated that replacing an older EHR with a new system resulted in a higher incidence of some types of prescribing errors. However, this follow-up study found that prescribing errors consistently decreased as users became more familiar with the new system and as the system was refined. Prior studies have also shown that at least 1 year of use is required to obtain the safety benefits of EHRs. The article provides an excellent example of the ongoing monitoring and adaptation required to effectively implement EHRs.

In this study, better safety climates in emergency departments were associated with more intercepted near misses but not with fewer preventable adverse events.

Pediatric nurses reported frequently violating medication administration policies, especially in emergency situations. The impact of these protocol violations on patient safety was unclear.

This commentary presents a model developed to explore how health information technology affects care delivery.

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

The implementation of new computerized provider order entry (CPOE) systems can have unintended consequences, including adverse clinical outcomes. As CPOE systems evolve, health systems are beginning to transition from older versions (with only limited decision support capabilities) to more sophisticated systems. This analysis of a primary care practice that underwent such a transition found fewer overall prescribing errors with a newer system. However, this improvement was largely due to the new system's ability to prevent "do-not-use" abbreviations in prescriptions; the incidence of other types of prescribing errors actually increased for the first 3 months after implementation. Even with experienced CPOE users, novel systems evidently have the potential to adversely affect patient safety.

Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.

… parental education is discussed in this AHRQ WebM&M commentary . …