Many labor and delivery wards have implemented continuous fetal and maternal monitoring to improve patient safety, but this continuous monitoring may also have unintended consequences, such as alarm fatigue. This labor and delivery ward sought to decrease the overuse of monitoring, and related false or missed alarms, on low-risk obstetrical patients. Through the development and implementation of a vital sign guideline assessment, the rate of alarms was decreased with no increase in maternal complications.

… without a title such as “doctor”. … Andraska EA, Phillips AR, Asaadi S, et al. Gender bias in risk management reports involving …

… and imprecise communication) team cognition. … Wooldridge AR, Carayon P, Hoonakker P, et al. Team cognition in handoffs: relating system …

… to transitions) to ensure safe transitions. … Wooldridge AR, Carayon P, Hoonakker P, et al. Care transition of trauma patients: Processes with …

… be paid to workflow and display/visual clutter. … Iqbal AR, Parau CA, Kazi S, et al. Identifying electronic medication administration …

… the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their … disclosure toolkit for use across the VA system. … Elwy AR, Maguire EM, McCullough M, et al. From implementation to sustainment: a large-scale …

… and opioid and non-opioid analgesics. … Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-patient …

Effective communication between patient and provider is key to successful deprescribing.  Participants in this study were asked to rate potential phrases a clinician may use to explain why stopping or reducing a medication is important. The most preferred phrase involved an explanation of risk of side effects associated with the medications while the least preferred options focused on the effort involved in taking the medication and “this medication is unlikely to help you function better”. Understanding the patient’s priorities can help frame the conversation around deprescribing.

Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.

Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.

… of care transition. … Belasen AT, Hertelendy AJ, Belasen AR, et al. Provider-patient communication and hospital …

… in cancer-specific and non-cancer care. … Jazieh AR, Akbulut H, Curigliano G, et al. Impact of the COVID-19 …

… with the lowest cost per event. … Merkow RP, Shan Y, Gupta AR, et al. A comprehensive estimation of the costs of 30-day …

This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.

… for common medical conditions. … Konopasky A, Artino AR, Battista A, et al. Understanding context specificity: The …

Second opinions are a strategy for reducing diagnostic or treatment errors. This article outlines reasons why patients seek additional expert opinion when determining a course of action and discusses non-clinical benefits of the practice.