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Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Res Social Adm Pharm. 2020;17:677-684.
This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.
Alqenae FA, Steinke DT, Keers RN. Drug Saf. 2020;43:517-537.
This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.

Latzke M, Schiffinger M, Zellhofer D, et al.  Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care [Epub 2017 Nov 28]. Health Care Manage Rev. 2020;45(1):32-40. doi: 10.1097/hmr.0000000000000188.

This study examined the impact of safety climate and team processes on patient safety events occurring during intrahospital transport. The authors analyzed 858 transfers occurring over a 4-week period and assessedsafety climate and team processes using standardized scales. After controlling for transport-, staff-, and ICU-related variables, the authors found that safety climate, team processes and transport training were associated with adverse events during intrahospital transport.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Gao H, McDonnell A, Harrison DA, et al. Intensive Care Med. 2007;33:667-79.
Rapid response teams are being widely implemented in hospitals worldwide. These teams are summoned to evaluate patients who meet specific clinical "triggers" (e.g., abnormal vital signs). This systematic review evaluated the ability of such triggers to accurately identify inpatients whose clinical condition is deteriorating. The false-negative rate of commonly used triggers was relatively high, meaning that a significant proportion of acutely unstable patients would not be identified by such criteria. This problem was noted in a prior negative study of rapid response teams. The authors recommend further research to determine the combination of triggers that most accurately identifies clinical instability.