Clinical Areas

Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024-2025, examines factors at different points in the medication administration process that contribute to medications not being provided reliably to support safe patient care. The first report in the series covered factors present in NHS emergency departments that influence timely medication administration. The second examines failures and improvement opportunities in anticoagulant medication administration processes.

Miscommunication is a major contributor to adverse events. This article describes the development of a framework to classify communication errors that contributed to a patient safety incident. Nine types of communication errors were identified. Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication errors.

Nursing leadership plays an important role in establishing a culture of safety. Findings from this cross-sectional survey with 255 nurse leaders highlight the important role of authentic leadership in fostering psychological safety and supporting nurses after serious medical errors. Survey respondents also endorsed the importance of formal support programs, including peer support, education, error analysis, and just culture.

Patients presenting with non-specific symptoms (NSSs) suggestive of cancer may experience diagnostic delays. In this study with four National Health Service (NHS) NSS cancer pathways teams, researchers identified distinct functions of the team, clustered in pre-testing assessment and information gathering and post-testing interpretation and management. There was wide variation between the sites in referral processing, patient coordination, team communication, and follow up.

Artificial intelligence (AI) systems effect decision-making using a variety of clinical and managerial healthcare data sets. This article explores the potential weaknesses in large administrative databases – weaknesses inherent in data submitted to, and recorded by, humans – which can undermine the accuracy and effectiveness of AI generated information.

Integrated care pathways (ICPs) are patient-centered and multidisciplinary. This article describes the development of an audit plan using Tracer methodologies to audit six oncology ICPs at a comprehensive cancer center. This methodology ensured the audit was patient-centered and focused on the patient's journey through several departments and facilities.

Health care is increasingly being provided remotely through telephone, video calls, and remote monitoring. Information on the prevalence and characterization of adverse events associated with telehealth is paramount to improving safety. This study analyzed 145 safety incidents related to telehealth at the VHA. The largest category was delays in care, and 90% of incidents resulted in no harm. Just over one-third were associated with the telehealth platform itself.

Medication errors and adverse drug events (ADEs) impact a significant number of patients every year. This article describes ongoing challenges (e.g., workforce limitations, polypharmacy) faced by safe prescribing and medication administration practices. The authors also highlight best practices and emerging approaches (such as artificial intelligence) that can advance medication and prescribing safety.

Electronic triggers and trigger tools are important methods of identifying and studying adverse events, such as missed opportunities for improving diagnosis (MOID). Using three triggers and the Revised Safer Dx Instrument, this study uncovered the frequency, type, causative factors, and severity of diagnostic errors in pediatric emergency departments. The overall frequency of MOID was 2.6% for the entire cohort, the majority of which resulted in patient harm.

Moving patients from one part of the hospital to another introduces clinical, communication and environmental risks that can reduce safety. This article discusses factors that contribute to patient safety events during intrahospital patient transport and presents a checklist as one mitigation strategy.

Production pressure and decision fatigue can pose patient safety risks. This scoping review explored how decision fatigue impacts decision-making in inpatient settings. The scoping review, which included 16 studies (primarily focused on emergency and intensive care settings), reported inconsistent findings and did not robustly address the role of clinician, patient, or work factors on decision fatigue.

Disruptive and unprofessional behavior can impact patient safety. This article highlights the effect that unprofessional behavior, including more subtle forms such as incivility and rudeness, has on patient safety, patient experience, and teamwork.

Poor handoff communication between teams can hinder safe patient care. This article describes the use of a risk management approach to improve handoffs from the operating room to intensive care. Frontline providers participated in a failure mode effects analysis (FMEA) to identify process failures, causes, and consequences related to handoffs. Participants reported that this approach helped them understand the handoff process beyond their individual roles.

Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event reports supports the spread of good ideas by generating interest in their application to drive patient safety improvement.

Long-term care residents are at increased risk for experiencing medication administration errors. Using semi-structured phone interviews with 12 nurses, this qualitative study identified several important factors for improving medication safety in nursing home settings, including user-friendly charting systems, improved nurse-to-patient ratios, and customized medication administration interfaces.

Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care. In this analysis of closed malpractice claims, anti-infectants, narcotics, and anticoagulants were identified in nearly half of the claims. Clinical judgment and communication were the most common contributing factors.

Information on the prevalence of errors in artificial intelligence applications and their impact on the healthcare system provides important guidance on development, implementation, and use. This article describes the development of a classification system for two popular uses of AI in health care: patient-facing large language models (LLM) and ambient digital scribes (ADS). Errors were prevalent in both types, with errors of omission being the most common. Although most errors in the LLM were categorized as having low clinical significance, 25% were categorized as high clinical significance (e.g., omissions of urgent guidance for conditions such as heart attack symptoms).