Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

… will enhance safety for staff, providers, and patients. … Benishek LE, Kachalia A, Daugherty Biddison L. Improving clinician well-being and …

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

… to improve team-based care. … Gregory  ME, Hughes AM, Benishek LE, et al. Toward the development of the perfect …

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

…   attributable to these laws.  … Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have …

This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.

… MM, Roche S, Greenberg Y, Folcarelli PH, Van Niel MB, Kachalia A. Ensuring successful implementation of …

A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.

This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.

This retrospective review of nearly 900 incident reports related to diagnostic imaging found that the most common type of safety problem was linked to the imaging procedure. Events associated with communicating abnormal results were less common but had a higher potential to harm patients. Most events had multiple contributing factors.

Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.

Multidisciplinary organizational efforts are necessary to reduce inappropriate prescribing of opioids. This commentary describes the design and implementation of an opioid stewardship program that combined the use of technology, education, and clinical strategies under strong leadership guidance as a cross-disciplinary strategy to address opioid misuse.

As the diagnostic safety field has matured, researchers are striving to better define the diagnostic process and identify failure modes that may lead to patient harm. This study utilized human factors engineering approaches to characterize the information sources used in radiologic diagnostic imaging according to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Most potential errors were related to person-related factors, such as inadequate communication between clinicians, rather than technological factors.

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

Communication-and-resolution programs, in which health systems and liability insurers disclose errors, apologize, and offer compensation to patients and families, led to declines in malpractice costs in prior studies. However, some have raised concerns that actual implementation of these programs may not have the same benefits. This prospective observational study reports results following implementation of a communication-and resolution-program at four hospitals in Massachusetts. Investigators report that the program was largely implemented as intended. Less than 10% of events met criteria for compensation, and the median payment was $75,000, allaying concerns about high costs of these programs. Lawsuits occurred in 5% of cases. The authors conclude that these results support further implementation and evaluation of communication-and-resolution programs. A recent PSNet interview with Michelle Mello, the lead author of this study, discussed legal issues in patient safety.

… of safety climate. … Pimentel MPT, Choi S, Fiumara K, Kachalia A, Urman RD. Safety Culture in the Operating Room: …

Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.