Patients in long-term or residential care facilities are at high risk of falls. In this study, researchers applied the International Classification for Patient Safety (ICPS) criteria to categorize types of falls occurring in residential aged care facilities in Australia. Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas. Resident pre-existing psychological or physical health were the most common contributing factor in falls that required a hospitalization.

Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.

Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.

Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.

Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.

Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.

The researchers in this study directly observed nurses administering medications to pediatric patients to measure the association between double-checking and medication administration errors. When double-checking was mandated, the researchers did not find any significant association with medication errors. When double-checking was not mandated but was performed, medication administration errors were less likely to occur and were less severe, but the association was not significant. These findings raise questions about the benefits compared to single-checking.

This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  

This article discusses the influence of artificial intelligence tools and cyber-social systems on human decisions in healthcare. Opportunities to use cyber-social systems in public and population health (e.g., disease tracking) and primary care (e.g., patient-facing technologies, such as symptom checkers) as well as approaches to exploit cyber-social systems within a learning health system are discussed.

Medication administration errors are common and account for a significant fraction of medication errors. This systematic review examined the effect of medication double-checks on medication administration errors. Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence to double-checking protocols. Only one high-quality study showed improvement in medication administration error rates when a double-check took place. No studies demonstrated differences in patient harm with double-checking compared to usual medication administration practice. The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking medication administration confers a meaningful safety benefit. A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy for verifying the order prior to administration, which led to a medication administration error.

Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.

This review examined whether use of health information technology could improve physician awareness of actionable test results and follow-up of test results. The included studies were of variable quality, and though some did demonstrate improvement in test result management using health information technology, there was no consistent effect. The authors conclude that health information technology alone is not sufficient to close safety gaps in test result management.

This simulation study compared medical students' performance of electronic prescribing with and without clinical decision support. Students were less likely to access outside references to verify that medications were safe when decision support was in place, even when the decision support was incorrect. The authors conclude that electronic prescribing should be redesigned to facilitate external verification of medication safety.

Health information technology (IT) implementation is a complex endeavor that requires a sociotechnical orientation to succeed. This article outlines nine key challenges to safety that must be addressed across the three stages of health IT: design and development; implementation and use; and monitoring, evaluation, and optimization.

This analysis of a previous simulation study of electronic prescribing examined the effect of cognitive load, or demand on working memory, on errors. This study found that physician participants who reported a lower cognitive load were more likely to make errors of omission, suggesting that they were not paying sufficient attention to the task. The authors conclude that errors may arise from a mismatch in allocating cognitive resources (how much attention is paid to a task) and the cognitive requirement needed to safely accomplish that task.

Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.

Artificial intelligence can improve practice by making synthesized data available in real time to inform frontline decision-making. This commentary describes factors clinicians should consider as artificial intelligence becomes more prevalent in health care and discusses how this technology can enable clinicians to focus on helping patients navigate complex care choices.