Transitions of care, whether from the hospital to the outpatient setting or within the hospital itself, represent a vulnerable time for patients. Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse events and errors, including medication errors. This study of 58 intensive care units (ICUs) across 34 United States hospitals and 2 Dutch hospitals sought to assess medication errors among patients transferred from ICUs. Of the 985 patients included in the study, almost half (46%) experienced a medication error during transition out of the ICU. Discontinuing orders and reordering medications at the time of transfer out of the ICU as well as daily patient rounding in the ICU were associated with decreased odds of medication error during transition. A past Annual Perspective discussed challenges associated with handoffs and transitions of care.

This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.

Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.

Excessive nursing workload is a known safety issue. This study examined whether nurse workload in the neonatal intensive care unit affected the quality of nursing care. Investigators measured workload using patient–nurse ratios, taking into account patient acuity, and a convenience sample of nurses also reported their perceived workload. Participating nurses were asked to report the care they provided, and missed care was defined as self-reported failure to provide any of 11 prespecified essential elements of nursing care. The authors identified a consistent association between perceived workload and missed care, suggesting that nurses' own assessments of their workload should be a safety consideration. A PSNet perspective explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.

Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing 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.

This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.