This infographic provides information about adverse drug events, including how frequently and where they occur and strategies to reduce risk of such errors (e.g., computerized provider order entry and barcode medication administration).

This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s death. The attention-grabbing design is an innovative method for demonstrating the context and emotional aspects related to an adverse event. The story implicitly illustrates the hidden curriculum of medical training that often rewards trainee autonomy and places retrospective blame on individuals. The final frame closes with the author reflecting on how this adverse event had a lasting effect on his psyche - a well-recognized phenomenon known as the second victim of a medical error. A prior AHRQ WebM&M perspective explored many issues related to diagnostic errors.

This commentary emphasizes the value of crew resource management and checklists in teamwork training programs to improve safety in surgical settings.

This study describes an experiential curriculum to engage and teach medical students about medication errors.

This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.

This piece illustrates how relying on color for identification and distinction of medications and containers could cause errors for patients with impaired color vision.

In this study, higher levels of professional commitment on the part of nurses correlated with higher levels of patient safety and patient-perceived care quality.

This study found that exposing students to a team-based patient safety event increased their knowledge of safety principles and also added value above that of learning only with other medical students.

Rapid response teams (RRTs) have proven to be very popular among bedside nursing staff, contributing to their widespread implementation despite equivocal evidence of clinical benefits. This study carried out interviews with nurses, chief nursing officers, and RRT members at 18 hospitals to obtain insights on how to successfully implement RRTs. Themes that predicted successful implementation included clear organizational support for the RRT, support for bedside nurses when the team is called, and less resistance from physicians to using the RRT.