… monitoring of patient safety and quality data. … Smits M, Langelaan M, de Groot J, et al. Examining causes and prevention strategies …

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.

Numerous studies have identified unintended consequences associated with health information technology (IT) and computerized provider order entry, but most of these focused exclusively on the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, extends prior studies by examining medication errors related to IT in community pharmacies as well as hospitals. Overall, nearly one in six medication errors was attributable to problems with IT. Human factors engineering issues, such as poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a founder of the human factors engineering field, was interviewed by AHRQ WebM&M in 2009.

Differences in safety culture between hospital units did not explain the variances seen in error reporting practices.

Conducted in 70 primary care clinics in the Netherlands, this study found that clinicians' perceptions of safety culture bore little relationship to the actual incidence of patient safety events in their clinics.

Many organizations issue alerts to warn clinicians and safety professionals about emerging safety issues. The Joint Commission's Sentinel Event Alerts and the Institute for Safe Medication Practices' Medication Safety Alerts are two prominent examples. The effectiveness of these alerts was examined in this Dutch study, which evaluated the degree to which hospital pharmacies implemented three specific medication safety recommendations made by the national Central Medication Incidents Registration (CMR) system. Many pharmacies had yet to implement any of the recommendations 2 years after they were issued, and only one of those recommendations had been implemented by a majority of pharmacies. The authors conclude that passive dissemination of medication safety information is likely an insufficient method.

This study sought to quantify adverse events associated with physical therapy and occupational therapy in the outpatient setting but was limited by incomplete record keeping.

This study found a low rate of patient safety incidents involving telephone care interactions. Most incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing medical advice by telephone.

Evidence from autopsy studies indicates that thousands of patients die every year due to missed or delayed diagnoses, leading to diagnostic errors being termed the "next frontier" in patient safety. This Dutch study used trigger methodology (based on the classic Harvard Medical Practice Study) to analyze the epidemiology and underlying causes of diagnostic errors in a broad sample of hospitalized patients. Approximately 1 in 250 patients experienced a diagnostic error, most of which were considered preventable. The contributing factors primarily centered around knowledge-based errors and faulty information transfer between physicians—a problem noted in prior studies of diagnostic errors. A Patient Safety Primer discusses the heuristics that cause physicians to err in the diagnostic process and the system failures that lead to delayed or missed diagnoses.

Structured interviews revealed that primary care physicians and nurses had a broad view of patient safety in ambulatory care, encompassing organizational, cultural, and professional factors.

Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.

Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.

This systematic review of studies of teamwork in health care found that adding personnel with specific clinical expertise to teams appeared to improve performance, but did not necessarily improve patient outcomes.

Root cause analysis is commonly used to identify underlying system causes of adverse events. However, this study found that interrater agreement on the number and type of root causes was only moderate.

This study analyzed adverse events in two primary care practices and found that half had health consequences and a third led to worsening of symptoms or an unplanned hospital admission.

… with acceptable reliability and good construct validity. … Smits M, Christiaans-Dingelhoff I, Wagner C, Wal Gv, …

Improving teamwork among providers of different disciplines is a vitally important step in developing a culture of safety. Despite the development of measurement tools and intervention strategies for addressing inpatient teamwork, comparatively little research has addressed issues of team and organizational culture in the outpatient setting. This study sought to evaluate the relationship between teamwork (measured by the Team Climate Inventory) and organizational culture and chronic disease outcomes in ambulatory clinics. Neither teamwork nor organizational culture at the clinic level was significantly correlated with process or outcome measures, but the authors caution that current measurement methods are not optimal for assessing safety culture in small office practices. A prior trial of crew resource management in an outpatient clinic did result in improved diabetes care.

Five methods of adverse event detection—physician reporting, pharmacist reporting, patient surveys, medical record review, and review of deceased patients—were compared in this study. No single method was unequivocally superior.

This article addresses the gap in health care quality and safety research and offers a list of topics for future study. The authors argue that the research community's attitude about this field of study must change.

Many health systems rely on telephone triage to determine the urgency with which a patient should be seen by a clinician. Prior research has demonstrated that errors in triage may lead to patient harm. In this study, standardized patients with a variety of symptoms contacted telephone triage nurses at four Dutch general practices. The investigators analyzed the accuracy of triage decisions by comparing the nurses' advice to the national guideline for telephone triage. Both underestimation and overestimation of the severity of patients' illnesses occurred, although errors were less frequent when nurses had received specific training in use of the guideline. A prior AHRQ WebM&M commentary discusses the potential pitfalls inherent to providing medical advice by telephone and strategies for minimizing patient harm in these situations.