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Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
van den Bemt PMLA, Idzinga JC, Robertz H, et al. J Am Med Inform Assoc. 2009;16:486-92.
This study discovered that medication administration at nursing homes is an error-prone process, particularly around administration techniques and wrong time errors. A past AHRQ WebM&M commentary discussed a case of a nurse who bypassed the safeguards of an automated dispensing system at a nursing facility, which led to a serious medication error.
Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-33.
Adverse drug events (ADEs) are common in the long-term care setting, in part because many residents are prescribed high-risk medications such as sedatives and anticoagulants. This cluster-randomized trial evaluated the effectiveness of a computerized provider order entry (CPOE) system at preventing ADEs in two long-term care facilities. The system was largely ineffective at preventing errors, with no significant difference in ADE incidence between intervention and control units. Limitations of the CPOE system likely contributed to the null result, as the system created many unnecessary alerts and had only limited decision support capabilities. An AHRQ WebM&M commentary discusses a case of a medication error associated with warfarin use at a skilled nursing facility.
Rochon PA, Field TS, Bates DW, et al. CMAJ. 2006;174:52-4.
This case report describes how the cascade of events that led to an error in a long-term care setting might have been avoided with a computerized system in place. The same authors previously provided an overview of their experiences in implementing computerized provider order entry (CPOE) in long-term care settings.
Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.