… Medication reconciliation at hospital discharge has become a mainstay of patient safety efforts with most of the focus … in medication reconciliation. … Latimer S, Hewitt J, de Wet C, et al. Medication reconciliation at hospital …

… BMJ Qual Saf … Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to …

Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.

… agreed with the specific events being designated as a never-event. The most commonly reported events were not …

… care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. … frequently problems with medications, accessing care in a timely way, and diagnostic errors . …

This systematic review found that pharmacist-led medication reconciliation after hospital discharge reduced medication discrepancies. However, the pooled studies did not demonstrate changes in the readmission rate or emergency department visits following medication reconciliation. The authors suggest further research is needed to determine the effect of medication discrepancies on patient safety.

Human factors engineering helps improve human performance and reduce the risks associated with user error. This commentary discusses the current integration of human factors engineering theories and methods into education and training. The authors outline tactics to help educators translate human factors engineering concepts into their programs such as building on what works well.

… efforts to enhance patient safety. Investigators employed a systems approach to reduce risks associated with repeated …

… science : IS … Implement Sci … Test result management is a critical aspect of ambulatory patient safety . This direct …

… … BMJ Qual Saf … The trigger tool approach, in which a prespecified value triggers medical record review to identify patient safety issues, is a method to detect adverse events. This study offered … from trigger reviews, suggesting that trigger reviews are a feasible strategy to enhance outpatient safety. …

… safety training and curriculum development. … McNab D, Bowie P, Morrison J, Ross A. Understanding patient safety performance and educational …

Barriers to achieving safe, high-quality health care are well known. This study described the myriad challenges faced by the National Health Service (NHS) in its quest to provide optimal patient care. The authors suggest that the NHS lags behind other safety critical industries in applying human factors principles.

… widely. The authors of this conceptual paper suggest that a systems approach will lead to a reduction in vulnerabilities and support a positive safety culture. They argue that human error should …

… in ambulatory practice remain rare. In this evaluation of a pilot program, the study team interviewed general practice …

… similar to prior studies . The authors describe a conceptual model to comprehensively address the safety of … laboratory testing and results management in primary care, a useful step for future interventions. …

… BMC Fam Pract … BMC Fam Pract … There is a consensus that training in patient safety must be … on the core skills that students should be taught. A prior study used a consensus approach to identify the key … widely in the United Kingdom. … Ahmed M, Arora S, McKay J, et al. Patient safety skills in primary care: a …

In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.

According to this study, the majority of health care providers trained in root cause analysis (RCA) in Scotland did not participate in actual RCA investigations following their training.

This study measured perceptions of safety culture in United Kingdom primary care settings, identifying benchmarks for future improvement opportunities.

… residents generally supported voluntary error reporting , a large proportion did not feel such reports were useful, nor …