Effective patient safety improvement efforts address safety threats at the individual, interpersonal, and organizational levels. This study characterizes safety measures described in incident reports from German outpatient care settings. Of the 243 preventative measures identified across 160 reports, 83% of preventative measures were classified by the research team as “weak,” meaning that they focus on influencing human behavior rather than on treating underlying problems (e.g., alerts, trainings, double checks).

Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review. 

Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.

… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is … incident is considered a voiceable concern. … Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable …

Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.

This review analyzed literature on safety improvement strategies within the framework of organizational and structural factors that affect patient safety in health care systems.

… science … Health Care Manag Sci … The authors describe a patient safety culture survey designed for use in the … care setting and discuss the process used to test the tool's effectiveness. …

… of family medicine … Ann Fam Med … The authors describe a state-based review of discharge diagnoses to identify …

This AHRQ–funded study applied new screening criteria to capture health care injuries that occurred before hospitalization, in addition to those during a hospitalization. Investigators used the Wisconsin Medical Injury Prevention Program (WMIPP) screening method to analyze more than 318,000 pediatric discharges from 134 hospitals. The overall rate of medical injuries was 3.4%, with the most frequent areas for improvement around medications, procedures, and devices. The authors suggest that use of the WMIPP screening process may serve as an important method to survey patient safety in large population-based samples.