… likely to experience a medication order error. … Blaine K, Wright J, Pinkham A, et al. Medication order errors at …

Patients' reports of safety concerns can reveal adverse events that would not be identified otherwise. In this cluster-randomized trial of patient engagement, patient volunteers read and classified incident reports submitted by hospitalized patients enrolled in the study. Following classification by patients, reports underwent a standardized, validated review by multiple researchers to determine if the event constituted a patient safety incident. Overall, about one-third of patient-reported concerns were deemed to be patient safety incidents. Medication safety issues were the most prevalent concerns. The authors conclude that patient reporting of safety events lends a unique and necessary perspective to error reporting. A previous PSNet perspective highlighted the advantages to and limitations of engaging patients in patient safety.

This study evaluated the implementation of a patient safety intervention. Frontline staff engagement with the intervention was highly variable and the intervention was not implemented as intended across the study sites. These results underscore the challenge of translating patient safety research into practice.

Although patient engagement is widely recommended as a patient safety strategy, its impact on patient outcomes is unclear. In this cluster randomized trial, hospital wards were designated either to receive usual hospital care or to engage patients in safety by providing a questionnaire and an opportunity to report their positive and negative safety experiences. Investigators compared a global measure of safety, which included pressure ulcers, venous thromboembolism, catheter-associated urinary tract infections, and falls, between wards that engaged patients through this intervention with those that did not. While the participating hospital wards were able to collect safety feedback from patients in a feasible and acceptable manner, researchers found no statistically significant differences in safety outcomes in the patient engagement wards and the usual care wards. The authors conclude that evidence is insufficient to recommend this questionnaire-based patient engagement strategy as a way to enhance safety.

The role of patients in promoting their own safety remains controversial. Although some studies have shown that patients are able to identify errors not detected via other means, others have shown that patients may conflate service quality with safety issues. In this feasibility study, authors describe the development and testing of an intervention designed to collect feedback from hospitalized patients about the safety of their care.

Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.

Patients are increasingly encouraged to participate in preventing and reporting errors. This study evaluated three different methods for capturing safety concerns from patients: bedside interviews, a paper-based form, and a patient safety hotline. Face-to-face interviews generated more than twice as many concerns per patient compared with the other strategies.

Patient engagement programs are being widely implemented as means of improving the safety and quality of hospital care, and prior studies have shown that patients can identify safety issues that go undetected by other methods. This study examined the relationship between patient and staff perception of safety and overall safety outcomes by comparing patient perceptions of safety (measured by the Patient Measure of Safety survey), staff perception of safety (measured by the AHRQ Hospital Survey on Patient Safety Culture), and quantitative measures of patient safety events (measured by the NHS Safety Thermometer). The investigators found that both Patient Measure of Safety and Hospital Survey of Patient Safety Culture results were correlated with objective measures of safety, and they appeared to contribute independently to predicting safety outcomes. This study provides further evidence for including patient perspectives in identifying and measuring safety issues.

An in-depth, qualitative analysis of a safety campaign at a hospital in the United Kingdom demonstrated variations in perceptions of its goals and utility between project leaders and frontline staff. The authors advocate for patient safety campaigns to be used with other interventions such as incentives and leadership development.

According to this interview study, clinical leaders perceive that appointing mentors to new attending physicians helps to improve patient safety. Mentors provided professional guidance, enhanced emotional well-being, and promoted organizational commitment which can contribute to a stronger safety culture. These findings add to literature advocating for leadership engagement in safety.

In a 2010 report, patient safety was described as a critical unmet need in medical and nursing education. Formal curricula have emerged, but incorporating these ideals into trainees' practices remains challenging. This randomized controlled trial compared two educational strategies, patient narratives of health-related harm versus traditional faculty-delivered teaching, on the attitudes of physicians-in-training towards patient safety. Using the Attitude to Patient Safety Questionnaire, researchers found no differences in the two groups. Those learners who received patient narrative teaching demonstrated both stronger negative and positive reactions to the curriculum than those receiving traditional instruction. These results suggest that patient narratives alone are unlikely to change trainee physicians' attitudes toward patient safety. A past AHRQ WebM&M perspective discusses the role of graduate medical education in patient safety.

Patients can make unique contributions to identifying safety hazards. This study reports on the validation of the Patient Measure of Safety survey tool, designed to elicit patient perceptions of safety in the hospital environment.

Early efforts to understand and analyze safety incidents in clinical medicine were drawn from a well-known James Reason book and his description of the "Swiss cheese model" for errors. Since that time, many researchers have tried to provide additional frameworks that help define the root causes and key failure modes. This systematic review analyzed nearly 100 articles to establish a contributory factors framework that could be applied to evaluating safety incidents in hospital settings. A set of 20 domains were ultimately outlined with most studies identifying individual factors, communication, and equipment and supplies as most frequently reported. The authors suggest that a consistently adopted framework would substantially improve our ability to not only identify contributing factors but also learn from them.

This study identified 10 latent failures that contributed to medication administration errors based on interviews with nurses and managers. Ward climate, the most prevalent theme, was noted to interact with other failures such as workload, team communication, and supervision and leadership.

This study found that providers were concerned about patients boarded on the wrong unit, unnecessarily increasing their risk for an adverse event.

Achieving medication reconciliation continues to present significant challenges, despite existing guidelines and its demonstrated impact on patient safety. Electronic health records (EHRs) and related tools have long been touted as solutions to bolster reconciliation safety. This study evaluated whether an EHR shared between outpatient and inpatient providers could reduce suspected medication discrepancies. Although errors were reduced, significant discrepancies persisted among various forms of reconciliation, including differences between what was in the record and what patients actually reported taking. Problems included outdated or incomplete medication information, incorrect information provided by patients, or mismatched information between the different sources. The authors argue that EHRs, as an added information vehicle, may help reduce reconciliation errors, but they caution that EHRs are only a tool (and not in themselves a solution) for safer reconciliation. A past AHRQ WebM&M commentary discussed whose job it is to assure safe medication reconciliation.

An important element of providing patient-centered care, active patient engagement is also a potential strategy to promote safety. Efforts to understand the patient's role in safety continue, despite concerns about shifting such responsibility to patients. This qualitative study explored patient and family members' perceptions about safety after recent encounters with the health care system. Investigators found that patients identified many safety concerns during their care experience. Patients' ability to speak up was influenced by the threat of harm, the relative importance of their concern given other patients' needs and staff workloads, and the consequences of speaking up. Those who did speak up reported varied responses from providers, including welcome reassurance and exacerbated anxieties. The authors advocate for “listen up” campaigns directed at providers that mirror Speak Up patient-driven campaigns.

This analysis of voluntarily reported medication errors found that the reports often did not yield useful data. The authors make suggestions, based on error theory, to improve reporting systems to enhance the ease of reporting and the quality of error reports.

This systematic review found limited evidence linking engagement of patients in safety to improved safety or clinical outcomes, with the exception of programs to encourage self-management of oral anticoagulants.

The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.