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Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.

Clinical staff often fail to call rapid response teams to evaluate deteriorating patients, even when objective criteria for calling the team are met. This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture of safety can result in failure to use the rapid response team when appropriate and can also lead to using the team as a workaround to compensate for poor interdisciplinary communication.

This study group created a standardized running sheet for documenting medical emergency team (MET) events at their medical center. About half of ward nurses felt that this tool improved patient handoffs to the arriving METs.

This commentary describes one hospital's approach to engage residents in improving patient safety.

An electronic system was developed in order to ensure correct assignment of hospitalist physicians to patients at admission and at the time of care transitions (e.g., discharge from the intensive care unit).

This study conducted telephone questionnaires of trainees and discovered several areas for improvement in handoff communications.

Structured reminders within an existing computerized order entry system increased implementation of recommendations made by consulting physicians.

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.

Medical emergency teams (METs, also known as rapid response teams) are being widely implemented in U.S. hospitals. Although their effectiveness in preventing adverse patient outcomes is uncertain, a major proposed benefit of such teams is to provide support for nursing staff. This study, conducted at an Australian hospital with a long-standing MET, surveyed ward nurses to determine if they understood the appropriate reasons to call the MET and evaluate if they felt the MET improved patient safety. Nearly all nurses felt the team helped provide more effective care for patients and helped educate nurses in caring for acutely ill patients. Nurses did not feel that they would be criticized for calling the MET. Despite the presence of objective criteria (eg, vital sign abnormalities) for calling the MET, most nurses preferred to use their clinical judgment to decide when to summon the team.

The author discusses how language barriers can compromise a patient's health care and highlights the need for reliable interpreters to communicate medical information.

The authors present a case study exploring information exchange in a patient care unit and suggest roles that can support patient safety improvement through more effective information flow.