Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Background And Objective: Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE).

Utilising improvement science methods to optimise medication reconciliation.

Background: In 2005, The Joint Commission included medication reconciliation as a National Patient Safety Goal to reduce medication errors related to omissions, duplications and interactions. Hospitals continue to struggle to implement successful programmes that meet these objectives.

Methods: The authors used improvement methods and reliability principles to develop and implement a process for medication reconciliation completion at admission at a large, paediatric medical centre.