Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2021;61:e46-e52.
This article describes a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.
Mazurenko O, Andraka-Christou BT, Bair MJ, et al. Jt Comm J Qual Patient Saf. 2019;45:241-248.
This interview study examined perspectives from nurses, physicians, and administrators about balancing adequacy of pain management with risks of opioid medications. Key strategies for minimizing opioid use included offering alternatives to opioids, setting feasible expectations for pain management, and using a team approach.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Researchers conducted eight focus groups to understand how to better engage Ethiopian hospital pharmacists in medication safety. Most expressed enthusiasm about having an active role in safety as long as concerns related to space, resources, and training were addressed. A recent PSNet perspective examined team-based approaches to improving safety during hospital discharge.
Antimicrobial stewardship has been highlighted as a strategy to improve antibiotic use in order to reduce hospital-acquired infections. This commentary discusses antimicrobial stewardship teams, their impact in the surgical setting, and the role of nurses in ensuring appropriate use of antibiotics.
Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.
Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.
This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121:948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.
The field of anesthesiology has achieved dramatic progress in safety by incorporating teamwork and human factors approaches into practice. This commentary outlines safety efforts in this setting, particularly around the creation of the Anesthesia Patient Safety Foundation and the Anesthesia Quality Institute, to frame how organizational partnerships enable continuous improvement. A past AHRQ WebM&M perspective explores insights from Dr. Jeffrey Cooper about patient safety in anesthesia.
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nurs Manage. 2014;45:26-31.
This commentary outlines an initiative at a 15-bed pediatric nursing unit that used quiet zones, safety huddles, and independent double checks to reduce medication errors of the type that reach the patient but neither cause harm nor require additional intervention.
This study analyzed unintended events reported by hospital staff to identify targets for intervention. The medication process and collaboration within the hospital were themes warranting further intervention.
A multidisciplinary team comprised of clinicians, patient safety experts, human factors engineers, and biomedical engineers used a user-centered approach to select smart infusion pumps as part of an overall effort to improve medication safety.
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