Reducing the risk of patient harm during anesthesia medication administration in perioperative settings has been a long-term goal in patient safety. SEIPS 101 tools, provide a series of practice-orientated techniques to apply systems model in real clinical practice, potentially offering a straightforward approach to mapping perioperative medication delivery systems. Data was collected during direct observations of thirty-eight anesthetics, totaling over 100 h on anesthesia providers' common tasks and interactions with people, environments, tools, and technologies. Observation data, notes, interviews, and literature were organized to create six SEIPS 101 tools demonstrating the complexity of anesthesia medication delivery. The Anesthesia PETT Scan represents the facilitators and barriers associated with differences in individual expertise, preferences, and potential conflict between providers. The People Map demonstrates the wide range of relevant individuals in medication delivery. The Task x Tools Matrix depicts the broad range of interconnected processes to provide anesthesia. The Journey Map describes the path used to deliver a medication. The Anesthesia Work System Interactions Map identifies necessary interactions that providers have with tools, tasks, people, and environment for successful anesthetics. The Outcome Matrix describes various stakeholder experiences and outcomes that contribute to overall system complexity. Identifying and describing the complexity in the anesthesia care delivery system is critical for effective and efficient process-centric interventions. This systems analysis may increase awareness to the limitations of current approaches and improve upon methods and interventions for understanding errors, safety, and the nature of clinical expertise and decision making.

Automated dispensing cabinets (ADCs) are used to store and dispense medications at the point of care. Medications accessed from an ADC before pharmacist order verification are removed using override functionality. Bypassing pharmacist verification can lead to medication errors; therefore, The Joint Commission considers overrides acceptable only in limited scenarios. During an 18-month period, the override rate in our perianesthesia care unit (PACU) was 17%, with oral midazolam accounting for roughly 40% of overrides. A multidisciplinary quality improvement (QI) project was initiated with a goal to reduce overrides by 10% (17% to 15%) by December 31, 2021.

Key drivers for reducing overrides included timely medication order entry, nursing practice to wait for verification, and timely pharmacist medication order verification. Interventions related to the latter two drivers included nursing education, individual interviews, and a workflow change involving nurse-to-pharmacy communication prior to medication overrides. Interventions were implemented in three Plan-Do-Study-Act cycles beginning in July 2021. Outcome metrics were average monthly percentage of total medication overrides and overrides for oral midazolam, which were analyzed using statistical process control charts.

Following interventions, the average monthly percentage of total medication overrides decreased from 17% to 8% in July 2021, and further to 4% in February 2022. Oral midazolam overrides decreased from 22% to 9% in July 2021, and further to 3% in February 2022.

Both total and oral midazolam overrides were reduced by changing nursing and pharmacy workflow. Reducing ADC overrides is a complex process balancing operational flow and safety efforts.

To examine the degree of left-to-right character overlap in medication names as they appear in real-world computer systems.

We programmed a computer to create and automatically analyze left-to-right character overlap in names appearing on 20,020 lists of real-world medication names. The lists varied in length from 100 to 500 medication names and were created by randomly drawing names from a pool of 2,249 medication names extracted from an operating medication use system database.

Overall maximum left-to-right character overlap varied in lists of 100 to 500 medication names from 4 to 29 characters (mode of 14 characters). For a small subset of names for high-alert medications that must never be administered in error, overall maximum left-to-right character overlap varied from 3 to 10 characters (mode of 6 characters). Further, for users searching for medications by name in computer systems, the keystrokes that do the most work to disambiguate medication names on a list are always the initial few keystrokes.

Medication name left-to-right character overlap on lists of names searched ranges widely. Instead of requiring all users to type a set number of characters when searching for medications by name, search safety can potentially be improved by upgrading computer systems to dynamically respond to each keystroke entered. Using incremental dynamic search, searchers would often be able to type fewer than 5 characters to isolate a single medication by name but would sometimes have to type many more than 5 characters to do so.

Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

Military environmental exposures and care for subsequent health concerns have been associated with institutional betrayal, or a perception on the part of veterans that the US government has failed to adequately prevent, acknowledge, and treat these conditions and in doing so has betrayed its promise to veterans. Institutional courage is a term developed to describe organizations that proactively protect and care for their members. While institutional courage may be useful in mitigating institutional betrayal, there is a lack of definitions of institutional courage in healthcare from the patient perspective.

Using qualitative methods, we sought to explore the notions of institutional betrayal and institutional courage among veterans exposed to airborne hazards (i.e., airborne particulate matter such as open burn pits; N = 13) to inform and improve clinical practice. We performed initial interviews and follow-up interviews with veterans.

Veterans' depictions of courageous institutions contained key themes of being accountable, proactive, and mindful of unique experiences, supporting advocacy, addressing stigma related to public benefits, and offering safety. Veterans described institutional courage as including both individual-level traits and systems or organizational-level characteristics.

Several existing VA initiatives already address many themes identified in describing courageous institutions (e.g., accountability and advocacy). Other themes, especially views of public benefits and being proactive, hold particular value for building trauma-informed healthcare.

An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.