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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.

Recent duty hour reforms are intended to improve patient safety and resident well-being. This study explored whether resident performance declines as a function of consecutive overnight shifts, but results indicate no significant trend in overnight report discrepancies between the night float resident and the daytime attending.   

This systematic review explored the different approaches taken by the United States and the United Kingdom to implement crew resource management (CRM) training. CRM in the United Kingdom had an emphasis on physicians and focused on skills outcomes using pre- and post-training questionnaires, whereas CRM in the United States focused on behavior outcomes and nontechnical skills utilizing multidisciplinary teams.  

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.

Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.

Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.

Teamwork is an important component of safety culture. This qualitative study found that medical and surgical trainees' perceptions of teams varied widely. The authors contend that the emergence of shift work may hinder trainees' ability to feel as if they are part of a team and can present a challenge to safety culture.

Obstetric care is considered a high-risk environment. Highlighting the importance of coordinated teamwork during obstetric emergencies, this review discusses strategies to augment clinical outcomes in this setting, including team training, communication improvement, and situational awareness.

Clinicians must routinely triage and manage clinical issues over the telephone, but prior research has shown that this process is often error-prone. This simulation study of telephone triage in hospitalized patients found bidirectional problems with communication, as nurses frequently failed to provide crucial information and physicians did not take appropriate action even when properly informed.

This survey of physicians about the UK equivalent of the "July effect"—a tradition of nearly 50,000 new doctors starting on the first Wednesday in August—found a high degree of concern for patient care, safety, and training. The authors conclude that there is a need for structural changes.

Duty hours for resident physicians in the United States have been limited to 80 hours per week since 2003, but more stringent European regulations now limit trainees to 48 hours on duty each week. This systematic review concurred with another recent review in finding that the American regulations have not negatively impacted trainee or patient outcomes, but found that the impact of European regulations has not been adequately studied.

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.