… or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest … for residents with respiratory conditions or pain. … Patterson ME,  Bollinger S, Coleman C, et al. Medication discrepancy rates and sources …

Production pressure—the pressure to continue work at maximum capacity—is a known threat to patient safety. This study analyzed the effect of production pressures by examining the relationship between two components of safety culture. Using data from the 2010 AHRQ Hospital Survey on Patient Safety Culture, the investigators found that respondents at hospitals that worked in crisis mode more frequently also were more likely to perceive care transitions as unsafe. As emergency department overcrowding has also been linked to safety issues, the results of this study argue for efforts to manage bed capacity and patient flow as a patient safety strategy. A recent AHRQ WebM&M commentary explores how communication breakdowns and production pressure can cause adverse outcomes and highlights how checklists can help prevent mistakes.

This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.

In this analysis of responses to the AHRQ Hospital Survey on Patient Safety Culture, pharmacists who perceived a culture conducive to open communication were more likely to voluntarily report medication errors.