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Children are highly vulnerable to safety risks associated with written handoffs. This article describes the impact of unit-wide implementation of a new handoff tool using electronic health record (EHR) auto-populated fields for pertinent neonatal intensive care unit (NICU) patient data. Handoff time remained the same, and the tool increased the accuracy of patient data included in handoffs and reduced the frequency of incorrect medications listing. 

This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.

This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).

The Medications at Transitions and Clinical Handoffs Toolkit (MATCH) provides strategies to implement and improve medication reconciliation in healthcare. This article describes the implementation of MATCH in a rural primary care clinic and the resulting improvements in medication reconciliation workflows.

This study examined patient safety issues stemming from health information technology (HIT)-related information management hazards. The authors identified eleven thematic groups describing such hazards occurring at a systemic level, such as fragmentation of patient information, “information islands” (e.g., nurses and physicians have separate information sets despite the same HIT system), and inadequate information structures (e.g., no drug interaction warning integrated in the chemotherapy prescribing tool).

Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.

The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.

Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.

This study reports on Kaiser Permanente's use of systems analysis approaches to review all cases of inpatient mortality, with the goal of identifying preventable harm.

This study provides a comparative description of two interventions to improve care transitions following hospital discharge. Home nurse visits uncovered 62% more medication discrepancies than those detected by telephone interview.

A comprehensive view of patient safety hazards requires identifying safety issues through multiple data sources. This Danish study analyzed safety problems in oncology care through voluntary error reports, retrospective chart review using the Global Trigger Tool, and patient reports. While each data source revealed unique hazards, common problems in this patient population included treatment-related harm (from chemotherapy and other procedures), health care–associated infections, and problems related to communication between providers. An AHRQ WebM&M commentary discusses a preventable complication in a patient receiving outpatient chemotherapy.