Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.

Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.

Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.

… J Patient Saf … Understanding human causes of diagnostic … assessment and testing phases of the diagnostic process. … Baartmans MC,   Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis …

This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.

… J Patient Saf … Prior research has estimated that 6% of …

Patient safety is an increasing area of focus within graduate medical education. Using data on residency educational climate, patient safety climate, and residents' self-reported patient safety behaviors from 31 teaching hospitals in the Netherlands, researchers found an association between safety climate and self-reported patient safety behavior.

This qualitative study assessed perceptions of teamwork and interprofessional collaboration between obstetricians, nurses, and hospital-based and primary care midwives in the Netherlands. Overall, obstetricians perceived teamwork to be better than participants from other disciplines. The gap between physicians, nurses, and midwives was largest with regard to perceived openness to sharing opinions and discussing new ideas.

Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, production pressures, and fatigue. This commentary reviews handover behaviors, tools that can enhance handover quality, and how to engage patients and families as information sources during handovers.

The use of readmission rates as a metric of care quality remains controversial, as United States–based studies have shown that only a minority of readmissions are preventable. This prospective cohort study, conducted in 4 European countries, sought to evaluate the preventability of 30-day readmissions after hospitalization from both clinician and patient perspectives. Investigators found that 27.8% of readmissions were considered predictable (by the majority of those interviewed) and 14.4% were considered preventable. However, there was little consensus between physicians, nurses, patients, and caregivers about whether readmissions were preventable and why readmissions occurred. The only factor that consistently predicted readmission risk was if patients reported not feeling ready to go home on the day of discharge. This study adds to the literature questioning the utility of readmission rates as a measure of the quality of care.

… Journal of patient safety … J Patient Saf … Most studies of safety culture have focused …

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Safety culture is critical to patient safety improvement efforts. According to this survey, health care professionals found that reviewing their own results on the AHRQ Hospital Survey on Patient Safety Culture was useful. However, not all respondents knew what actions they could take to improve safety culture.

Incident reporting systems and root cause analyses remain the main mechanisms by which adverse events are identified and reviewed. This study sought to determine whether more localized, unit-based incident reporting systems might provide better insight into how patient safety incidents vary across hospital units and services than hospital or national level reporting systems. While similar safety issues and root causes were identified across all units and services, medication safety issues were more common on internal medicine and surgical units. On the other hand, collaboration issues were more frequent in emergency medicine units. These findings suggest that localized safety reporting systems might provide information that could promote improvement efforts.

… that had the potential to impair patient safety. A WebM&M commentary discussed a serious medication error arising …

This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.

… the International Society for Quality in Health Care … Int J Qual Health Care … In this study, health care organizations …

Comparing adverse event reports from patients who died in the hospital versus patients discharged alive, this chart review study found that preventable adverse events were more likely among those who died. The authors suggest that examining deaths alone does not provide a complete picture of the epidemiology of adverse events and recommend review of multiple outcome types.

The variable success of patient safety interventions has been attributed to the context in which these strategies have been implemented. In this systematic review, researchers found that contextual aspects that influence success of interventions are not systematically examined or reported, hindering understanding of how context affects implementation of patient safety efforts.

This retrospective study in the Netherlands encompasses three national major adverse event studies. These authors previously reported that the adverse event rate in the Netherlands had increased between 2004 and 2008. In this current study, there was no change in overall adverse event rates in 2011/2012 compared to 2008, while preventable adverse events were markedly reduced by 45%. Following multiple adjustments, this decrease was still evident (30%), though no longer met statistical significance (p=0.10). The decreased harms were seen in areas addressed by national safety programs implemented during this time, suggesting a positive effect from these efforts. A related editorial by Charles Vincent and Rene Amalberti discusses the expanding scope of patient safety as more medical harms become regarded as preventable. A second editorial by two of the journal's editors discusses the degree to which the nonsignificant reduction in preventable adverse events plausibly represents improvements from a national patient safety program in the Netherlands. It also advances the idea that the results highlight some of the limitations of adverse events as a measure of progress in patient safety, a point also made in the editorial by Vincent and Almaberti.