Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.

Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.

Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.

By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).

The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was a seminal moment in the patient safety movement. This bibliometric analysis found that the report has been mentioned in over 20,000 scientific publications since 2000, but that the themes of recent research do not necessarily align with the initial focus of the IOM report. For example, research on incident reporting and systems approaches to improving safety are underrepresented relative to their emphasis in the IOM report.

Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.

Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the United States. This article describes the development of the Child Health PSO and how it evolved into a learning network through alignment around a common goal, collaboration, and information sharing with high levels of engagement from participating children’s hospitals.

Quality measurement is increasingly being incorporated into policies outlining healthcare provider reimbursement. This study compared quality measure calculations between an individual electronic health record (EHR) source and the same EHR source combined with health information exchange (HIE) data. The results show that adding HIE data changed 15% of quality measure calculations. The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate and representative quality measurement.

Although medication reconciliation is a common strategy to improve medication safety, barriers to implementation and threats to safety persist. Based on events reported to the Pennsylvania Patient Safety Reporting System, the authors characterized serious events related to medication reconciliation. The most common process failures contributing to patient harm occurred during order entry/transcription and resulted most frequently in the wrong dose or dose omission. The authors suggest risk reduction strategies including defined clinician roles for medication reconciliation, listing the indication for prescribed medications, and adding anticonvulsants to processes for medication with high risk for harm.

The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.