Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.

This qualitative study sought to identify barriers and enablers influencing stakeholder support of the Operating Room (OR) Black Box, an audio-video recording device similar to that used on airplanes. Stakeholders were mostly supportive of the OR Black Box, but several potential barriers were identified, such as time pressures in the OR and perceptions that the Black Box may negatively impact clinical performance. Authors concluded that the OR Black Box must be positioned as a patient safety initiative to improve practice.

This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.

In this cross-sectional study, researchers evaluated medication safety letters issued by Health Canada, the United States Food and Drug Administration, and the United Kingdom Medicines and Healthcare products Regulatory Agency over a 4-year period to evaluate consistency of structure and content as well as timing and commonality of subject matter. They found significant differences in the medication safety letters issued by all three agencies with regard to both the timing and the focus. The authors suggest that better coordination across these bodies might improve patient safety.

… events while hospitalized, as discussed in a prior WebM&M commentary . This literature review found a need for …

This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.

Computerized provider order entry (CPOE) is one of the most widely recommended—and underutilized—safety strategies in health care. Prior research has argued that CPOE must be combined with decision support, ideally at the point of care, in order to effectively change clinician behavior. However, this meta-analysis of 32 trials of point-of-care computer reminders found only small overall improvements in adherence to target processes of care. A few trials reported much larger improvements, but the reasons for this are unclear, probably reflecting a combination of specific system and reminder design features, and perhaps cultural or contextual features of the institutions. Until further research identifies the specific design and contextual factors that reliably predict clinically worthwhile improvements in care, hospitals implementing CPOE may continue to find themselves conducting exercises in trial and error.

This systematic review found that computerized reminders for physicians were generally associated with small improvements in providing appropriate care.