… American journal of obstetrics and gynecology … Am J Obstet Gynecol … Patient safety has been described as an … training. This commentary provides information about a national program to build faculty competencies at the …

In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.

The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.

… The New England journal of medicine … N Engl J Med … Antibiotic-resistant bacteria, such as … In this cluster-randomized trial conducted in 18 ICUs, a protocol that involved universal surveillance and barrier …

… The New England journal of medicine … N Engl J Med … Despite the past decade's intense focus on patient … medical records from 10 North Carolina hospitals over a 6-year period, using the Institute for Healthcare … of the state of the field, including a commentary by Dr. Robert Wachter and a plenary session at the National Patient …

This study found satisfactory reliability between internal and external reviewers using the IHI Global trigger tool to identify adverse hospital events.

A recent report by the National Patient Safety Foundation challenged residency programs to train housestaff in patient safety and quality improvement. This study finds that, in addition to formal curricula, residents are increasingly learning patient safety principles through informal and hidden curricula in teaching hospitals.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse … events despite their known limitations . Heparin is a high-risk medication that frequently generates incident …

… and safety. Investigators found no relationship between a hospital's quality status and its residents' curriculum or understanding of quality and safety. While a few programs had formal curricula, the majority of …

Medication errors are common in pediatric inpatients, but the best method of addressing them remains unclear. Studies of technological interventions, such as computerized provider order entry, have yielded inconsistent results. In this controlled trial, clinical pharmacists were deployed in the intensive care unit (ICU) and general medical and surgical wards in a pediatric hospital, and their effect on prevention of medication errors was assessed. Serious medication errors (including near misses) were significantly reduced in the ICU. No effect was seen on medication error rates for general ward patients, although the baseline rate of errors was much lower in those areas. A prior review documented the effectiveness of pharmacists at preventing medication errors in a variety of inpatient settings.

Academic medical centers (AMCs) face unique challenges in translating their innovation in safety and quality research into clinical performance. This study examined discharge data from 79 AMCs to generate a scoring method for measures of safety, mortality, clinical effectiveness, and equity of care. After identifying three top performers and three average performers, a group of surveyors visited each site without knowledge of their score and made an objective assessment of the factors associated with their performance. The authors highlight the importance of a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration as key predictors of top performers. Similar to a past study that evaluated safety culture in AMCs, the authors emphasize that the actions of senior executives and department chairs do impact care at the bedside.

… The Journal of pediatrics … J Pediatr … This study discovered that children with multiple … prescriptions were at increased risk for suffering a preventable adverse drug event. Improved communication …

The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.

… events (AEs), have been used to screen for errors in a variety of clinical settings . This AHRQ–funded study used methodology similar to a prior study in adult intensive care unit patients to develop a chart-based set of triggers for error identification in the …

… The New England journal of medicine … N Engl J Med … The author argues that a systems approach  to hand hygiene is only useful if …

… study demonstrated that more than half of the patients in a single neonatal intensive care unit are at risk for …

This study found that medical errors often occur in patients with bronchiolitis, even more so in the critically ill.

… J Am Med Inform Assoc … J Am Med Inform Assoc … This study examined the utility of a multimedia kiosk to capture parents’ knowledge of …