Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares recommendations to enhance handoffs and information sharing amongst care teams and with patients.

Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.

Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.

Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.

Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.

Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.

Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted investigations and describes strategies to improve maternal safety, including standardizing procedures and enhancing communication.

Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.

Patient engagement is increasingly recognized as a key strategy to enhance safety in health care. This article describes how failure to communicate effectively with patients can reduce safety and outlines tactics to involve patients and families in care transitions.

Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.

Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.

Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.

Although health information technology presents opportunities to improve patient safety, it can also introduce risks. This commentary discusses how insufficient interoperability, data integrity, training, and protection against copy-and-paste errors can hinder optimal use of electronic health record systems.

This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.

Reporting on serious lapses in the care provided by the military health system, this newspaper article highlights how systemic problems, such as inadequate review of incidents, poor communication, and lack of transparency, can contribute to patient harm.

This news piece details the pervasiveness of unreported medical errors and describes the hospitalist perspective on initiatives to improve reporting and prevent adverse events.