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Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

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 found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.

The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.

The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.