Overcrowding in the emergency department (ED) and boarding can place patients at increased risk for adverse events. This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and enhance patient safety in overcrowded EDs, such as checklists, huddles, and resource allocation.

Quality improvement and patient safety initiatives require incredible human and financial resources, they so must be selected carefully to achieve the greatest return on investment. This article describes important considerations for hospital leaders when selecting and implementing initiatives. Safety culture, policies and procedures, supporting staff, and patient engagement were notable themes. The included "patient safety governance model" provides a framework to develop patient safety policy.

Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

Reducing or preventing inpatient falls is a common focus of patient safety improvement efforts in hospitals. This study in three orthopedic and three geriatric wards describes multidisciplinary communication about falls prevention strategies. Risk assessments and categorization (e.g., high- or low-risk) were discussed in conjunction with strategies to focus on modifiable risk factors.

Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.

Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.

Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.

Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.

Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.

In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.

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Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.

Children with intellectual disabilities can be at higher risk for patient safety events. Based on semi-structured interviews and focus groups with healthcare professionals, this study describes several themes regarding healthcare professionals’ perspectives about patient safety considerations when caring for children and young people with intellectual disabilities. Findings underscore the importance of considering additional vulnerabilities, improving engagement with patients and families, and mitigating negative attitudes and biases.