The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

The use of PRN (“as needed”) medications is a common source of medication errors. The authors describe the implementation of staff education and a pediatric intensive care unit (PICU) order set (with predefined PRN orders), which led to increased compliance with Joint Commission medication management standards. The related editorial discusses how investment in human factors and ergonomics can contribute to healthcare quality and safety improvements.

This study assessed the impact of electronic health record (EHR) interventions to standardize opioid prescribing practices across a large health system. Interventions included (1) deleting clinician preference lists, (2) default dose, frequency, and quantity, (3) standardizing formularies, and (4) dashboards with current opioid prescribing practices. In the 12 months after implementation, there was a decrease in the rate of opioid prescriptions overall, prescriptions exceeding three days, prescriptions exceeding prespecified morphine equivalent doses, and non-formulary prescriptions.

The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.

Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.

This study used one cancer hospital’s incident reporting system to evaluate trends in medication error reporting before and after the implementation of a new electronic health record (EHR) system. After implementation, decreases in reporting were observed for wrong-dose, overdose, wrong duration, and wrong frequency medication errors, likely due to EHR tools such as hard stops on medication doses or prohibiting early or late administration.

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.

This simulation study randomized physicians to identify the correct diagnosis in a standardized case, either with the aid of a debiasing exercise or without any prompting. Even though the participants believed that the debiasing tool was effective, it did not improve diagnostic accuracy. These results underscore the challenge of enhancing diagnostic cognition.

Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.

This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Insulin is known to be a high-risk medication. This pre–post study found that introduction of a standardized sliding scale insulin order led to decreased rates of insulin prescribing errors. However, the incidence of hyperglycemia or hypoglycemia did not change. This study demonstrates how standardization can support patient safety.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.