Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors

This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.

Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.

The limitations of standard incident reporting systems have been well documented. This interview study investigated health care providers' perceptions of safety events and incident reporting in rehabilitation centers. Researchers asked participants whether hypothetical scenarios constituted safety problems that they would report. Participants were more likely to report events with severe harm to patients, events classified as critical incidents, and events within their own scopes of practice. The authors suggest that interprofessional team training to enhance safety culture could improve reporting, as has been shown in other care settings. This study did not include patient perspectives, which might have brought to light other possible interventions, as suggested in a past AHRQ WebM&M perspective.

Documentation of important care transition information, such as medication changes and pending test results, was often lacking when patients were transferred from a hospital to a rehabilitation facility.

A nursing survey, The Missed Nursing Care Survey [MISSCARE Survey], was developed to evaluate the reasons for omission of standard nursing care practices.

The authors present six case studies of failures in occupational and physical therapy and analyze the ethical issues involved in each case.