… Residents and staff were tested for COVID-19 and completed a symptom questionnaire assessing systems for the preceding …

This analysis of 220 national incident data from England and Wales’ National Reporting and Learning System  sought to identify safety concerns experienced by children on long-term ventilation at home. The most common problems were with the equipment and devices (e.g., faulty or damaged equipment) or procedures and treatment (e.g. tracheostomy tube becomes dislodged). The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change or hospital admission. Identified contributory factors involved the patients, staff performance, family caregivers, equipment, organizational, and environmental features.

… residents in quality and safety efforts has become a major focus of graduate medical education . This study describes the development and impact of a pediatric resident-led safety council, which improved …

Computerized provider order entry (CPOE) systems improve medication safety by electronically alerting providers to potential prescribing errors and medication safety issues. If a system generates an excessive number of warnings, this can lead to alert fatigue and providers may unintentionally override appropriate alerts. This systematic review examined the impact of different types of medication prescribing alerts in CPOE systems on provider behavior. Researchers included 23 studies and found that the most common alert categories included drug–condition interaction alerts, drug–drug interaction alerts, and corollary order alerts. Although 17 of the studies demonstrated a statistically significant benefit from the intervention alerts, the authors conclude that further research is needed to understand if certain categories of alerts are more effective than others. An Annual Perspective discussed CPOE as it relates to patient safety.

… of including such curricula in obstetrics and gynecology . A past PSNet Annual Perspective discussed safety and medical …

Patients hospitalized with cardiovascular conditions are particularly vulnerable to medication errors. This review explains how drug shortages associated with cardiovascular medications pose risks to patients and provides recommendations for clinicians, policymakers, and manufacturers to address this problem.

… and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an … … Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and senders …

… Crit. Care Med. … Crit Care Med … Severe sepsis has been a focus of quality efforts . This retrospective study … which together accounted for about one-third of cases, had a higher mortality rate and were more severe and costly than … cause significant harm and costs to patients. In a related study, researchers examined readmissions following …

… … JAMA Intern Med … Polypharmacy in older patients is a predictor of medication errors. However, deprescribing—stopping or reducing medicines in a patient's drug regimen—can introduce opportunities for harm if not done appropriately. This commentary presents a protocol to enhance the safety of deprescribing by …

This study sought to validate 25 factors that critical care nurses perceived to be associated with subsequent deterioration following intrahospital transfer from intensive care units (ICUs) to ward inpatient units. Patient complexity was most commonly linked to post-ICU adverse events, while specific system factors were associated with a lower proportion of post-ICU adverse events. These results suggest that multiple system-level interventions would be needed to improve the safety of ICU-to-ward transfers.

This commentary discusses how Reason's accident causation model is used to analyze adverse events and identify factors that contribute to error.

This commentary details how the delay of electrocardiogram data distributed via wireless telemetry systems can affect patient safety and provides recommendations to prevent and mitigate such delays.

This retrospective study explored factors that led to diagnostic errors in magnetic resonance imaging of suspected breast cancer.

This piece describes the medication reconciliation process and discusses limitations of current information technology applications.

… … Maternity care professionals at all levels identified a high level of concern about patient safety in obstetrics, …

… research … Health Serv Res … Executive walk rounds are a recognized technique for improving safety climate , by … authors conclude that while executive walk rounds are a potentially valuable safety intervention, successful …