This article describes the efforts towards high reliability undertaken by one specialty hospital for medically complex children and adults with intellectual and development disabilities. The organization employed a multi-pronged, data-driven approach involving training and education in quality management and patient safety and principles of high reliability organizations. Improvements in medication errors and hospital-acquired pressure injuries were observed, but employee engagement survey results reflect concern among staff that an emphasis on data may detract from patient care. 

Chemotherapy administration is a potential source for errors. This study evaluated trends in chemotherapy error reporting before and after EHR implementation. Errors arising from the wrong dose decreased after EHR implementation, while errors arising from missing dose or delayed delivery increased. 

This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.

This study examined the concordance between structured medication lists in the electronic health record and unstructured physician progress notes for antibiotic medications being used to treat keratitis, an eye infection. Researchers found that 23% of prescribed medications differed between the progress note and the structured medication list, highlighting the need for and the challenges in conducting medication reconciliation.

This cross-sectional study examined outcomes for Medicare patients undergoing complex cancer surgery at U.S. News and World Report top-ranked cancer hospitals and their affiliates. Investigators found that surgery performed at affiliated hospitals was associated with higher 90-day mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the study. The authors suggest that while affiliated hospitals may share branding with top-ranked cancer facilities, further study of such networks is necessary to inform care for cancer patients.

Although the introduction of new technology in health care is crucial for advancing patient care, unintended consequences are a well-recognized safety challenge. In the field of surgery, innovation ranges from small improvements to drastic change, but there is no clearly established model for evaluating proposed innovations. This study examined the impact of a team of surgical quality officers and perioperative nurses tasked with reviewing proposed surgical innovations, including novel devices and procedures at a single cancer center. Investigators found that compared to the prior processes in place, this team evaluated new products more quickly, decreased the time between product proposal and the intraoperative trial if necessary, and reduced the rate of device-related complications from 10% to 0%. A past PSNet perspective discussed the evolution of patient safety in the field of surgery.

This study describes a quality improvement program that included chart review of patients taking high-dose opioids for noncancer pain and targeted feedback to clinicians with management recommendations. The program resulted in a decrease in overall opioid use as well as a reduction in coprescribing of benzodiazepines and opioids. Patient adherence to visits with their primary physician remained stable during the study period.

As outpatient surgery becomes more prevalent, attention around related safety concerns grows. Researchers analyzed postprocedure emergency department visits and hospital admissions to better understand factors associated with the safety of outpatient procedures performed within the Veterans Health Administration.

This study examined reports stemming from retained guidewires, a never event, across Veterans Affairs hospitals. Common causes included inexperience, lack of checklists, and insufficient standardization. The authors recommend applying human factors approaches to prevent this adverse event.

Alert fatigue associated with electronic health records (EHRs) contributes to primary care physician burnout and can increase medication errors. The phenomenon is especially well-described in the Veterans Affairs (VA) system, where providers receive more than 100 alerts per day, which require an average of 85 seconds to address. This study describes a nationwide VA initiative to reduce EHR alerts in primary care and teach providers to process alerts more efficiently. Alerts decreased by a small but significant amount—from an average of 128 per day to an average of 116 per day. Providers who received the most alerts before the initiative experienced the largest alert reduction. A PSNet perspective described a way forward in improving EHR safety.

Opioid and benzodiazepine coprescribing leads to increased risk for medication adverse events. This interrupted time-series analysis demonstrated that a computerized provider order entry alert about opioid and benzodiazepine coprescribing led to decreases in coprescribing for high-risk patients compared to the time period before the alert was introduced and compared to a control site that did not receive the alert. The authors conclude that medication alerts can reduce high-risk prescribing practices.

Communication failures are known to contribute to medical errors. In the field of aviation, crew resource management is used to teach teamwork and effective communication. In this study, researchers evaluated the impact of a team training program developed by the Veterans Health Administration National Center for Patient Safety and modeled after crew resource management training. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate prior to and after the training. They found that scores on the 27-item survey increased on all questions from baseline to 1 year and conclude that this type of team training improves patient safety by enhancing teamwork and ensuring effective communication among clinicians. A PSNet perspective provides insights on team training.