Previous research has identified gaps in medication reconciliation practices among hospitalized children. This quality improvement found that increased utilization of a patient-friendly discharge medication platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge medication reconciliation in pediatric acute care patients.

Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.

Experts have advocated the importance of establishing the business case for safety. This article summarizes approaches to establishing the business case for safety through the use of telehealth case-based vignettes as examples. The authors discuss challenges for establishing a business case for safety and future directions.

This article explores one hospital’s use of facilitated apparent cause analysis  (ACA), which is defined as a limited investigation of a safety event resulting in limited or no harm and allows for fewer resources and a focus on preventative strategies. The article compares ACA versus root cause analysis and describes the process for completing facilitated ACA and the framework for an effective ACA, which includes (1) identifying the right event, (2) assembling the right team, (3) conducting the right analysis, and (4) focusing on the right action plan.

Incident reporting is widely utilized to detect adverse events and near misses, but underreporting remains a problem. This study describes a quality improvement initiative to increase event reporting across a pediatric health care system.

This commentary explores the unique challenges involved in integrating core principles of safety and quality improvement into otolaryngology–head and neck surgery education and describes strategies to address them. The authors draw from the experience of other specialty-focused medical education efforts to suggest topics to cover, effective ways to deliver content, and morbidity and mortality conferences as elements of successful programs.

This survey of otolaryngologists found very little overall progress in self-reported patient safety errors compared with a similar survey in 2004. For instance, wrong-site surgeries continue to occur despite garnering major attention over the past decade and being classified as a never event.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

A novel trigger tool intended to detect errors in pediatric otolaryngology patients unfortunately missed many cases of preventable adverse events.

This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.

Retrospective chart review identified many errors (primarily in documentation) among pediatric otolaryngology inpatients but no major morbidity or mortality.

This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.

The investigators surveyed otolaryngologists regarding errors and found that the otolaryngologists disclosed mistakes to their patients, experienced emotional reactions, and took corrective actions.

The authors assessed the literature specific to errors and adverse events in the practice of otolaryngology, summarize the findings, and suggest future actions to manage errors in their specialty.