Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

… J Am Board Fam Med … Identifying barriers and facilitators of … medication safety in primary care: a systematic review. J Am Board Fam Med. 2022;35(3):610-628. …

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

… tools for use by practitioners, researchers, and others. … Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. Epub …

Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.   

… J Patient Saf … The aim of the Patient Centered Medical Home … safety culture in medical homes: a coincidence analysis. J Patient Saf. Epub 2020 Aug 3. 10.1097/pts.0000000000000752 …

This commentary describes how human factors and ergonomics can contribute to the COVID-19 pandemic response, using the example of workflow redesigns in a pediatric ambulatory care clinic.  The authors discuss Just-in-time (JIT) training, adapting workflow processes, identifying potential failure modes and safety hazards, and revisions to protocols and processes to provide safe care to patients during the COVID-19 pandemic.

Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care.  Understanding these barriers and facilitators can guide future endeavors to improve care transitions.

This narrative review describes the Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models, which provide a framework for integrating human factors and ergonomics into healthcare quality and patient safety improvements. The authors propose a SEIPS 3.0 model which would include the patient journey, defined by the authors as “the spatio-temporal distribution of patients interactions with multiple care settings over time.”

… improving physician satisfaction with the technology. … Carayon P, Hoonakker P, Hundt AS, et al. Application of human factors to improve …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Complex medical therapies such as …

Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.