Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Medication-related adverse events (MRE) occur frequently during anesthesia care and more research into preventing them is needed. This article presents a descriptive analysis of the MRE reported to the Spanish Anaesthesia Incident Reporting System database during the decade from 2008 through 2017. Of the 1970 MRE identified, the highest number (42%) occurred during the administration phase, and a greater percentage of administration-related MRE resulted in harm to patients (44% as opposed to 31% over all 1,970 events). The authors identified patterns and specific causes of MRE that they suggest could be mitigated using proven systems solutions.

Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.

Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.

Despite the well-documented prevalence of adverse events after hospital discharge and a growing policy focus on preventing readmissions, the factors leading to poor care transitions are not well understood. This qualitative study from Spain used in-depth interviews with patients, hospital staff, and primary care providers to better define the mechanisms by which adverse events and readmissions occur. The investigators found that discharge processes are often haphazard and a major source of frustration for hospital providers, and that patients often shoulder the burden of communicating clinical information to their primary care providers, which leaves those with limited health literacy particularly vulnerable to errors. These findings mirror and expand upon prior research. This study is part of a large, multi-national effort to improve the quality of patient handovers.

Using the example of an initiative to prevent adverse events after hospital discharge, this study presents a framework for estimating the cost effectiveness of proposed interventions to improve patient safety.

Care transitions remain a particularly vulnerable time for patient safety, leading to an increasing emphasis on effective handoff communication. Adverse events following hospital discharge are common, affecting nearly 20% of patients. This review summarizes interventions aimed at improving patient discharge from hospital to primary care; a number of effective strategies and measured outcomes are compiled. The efforts described are primarily focused on smoothing the coordination of care and communication between hospital and primary care providers and pharmacists. An AHRQ WebM&M conversation with Dr. Vineet Arora explores extra-hospital and intra-hospital handoffs.

This study used structured observations to identify effective teamwork behaviors and illustrated that high performing teams are more resilient when operations become more challenging. However, patient outcomes may be worse with higher teamwork levels because those cases are more complex.

… supervision in clinical settings. … Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do …

Medication reconciliation—the process of cross-checking patients' medication lists to correct errors and inadvertent omissions—was named a National Patient Safety Goal in 2005. Despite this, no consensus exists yet as to the best method of accomplishing medication reconciliation. This description of the process of implementing medication reconciliation at an urban public hospital includes much information that will be helpful for hospitals undertaking a similar process. The authors detail the barriers faced in developing the system (which was incorporated into an existing computerized order entry system), encouraging use of the system, and improving it based on user feedback. Prior research in this area has demonstrated the effectiveness of pharmacists at carrying out medication reconciliation.

In this study, researchers evaluated the culture of safety in pediatric cardiac surgery teams by using a survey based on the Safety Attitudes Questionnaire. Overall, teamwork was rated relatively low, similar to prior research analyzing operating room safety culture.

Medical students and residents are exposed to medical errors early in the training process, but formal patient safety training remains in its infancy. This survey of medical students and residents at an academic medical center sought to evaluate trainees' knowledge and attitudes toward important safety concepts. Trainees generally understood the importance of safety measures, but noted significant barriers to reporting errors and did not report positive learning experiences when errors occurred. Although the study is hampered by a relatively low response rate, the authors note that these responses may indicate a suboptimal culture of safety that limits the use of patient safety as a learning tool. A prior AHRQ WebM&M commentary discusses the barriers students may face in reporting errors due to the authority gradient, and a prior study explores educational strategies for encouraging resident learning from errors.

Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.

This commentary builds on the notion that our health care system requires structured efforts to improve safety and reliability. The authors summarize five primary barriers: accepting limitations on maximum performance, abandoning professional autonomy, transitioning from the "mindset of craftsman to that of an equivalent actor," needing system-level arbitration to optimize safety strategies, and simplifying professional rules and regulations. Each of these barriers is discussed with thoughtful perspective on both the associated historical and current contextual factors. In comparing safety strategies with other industries, a specific health care framework is also offered, raising distinctions that pose unique challenges. The article concludes with graphic presentation of a strategic view of safety in health care and the construct for a two-tiered system in which one system achieves "ultrasafe" status while the other does not at a calculated and accepted risk.

… in these areas. … Baker DP; Salas E; King H; Battles J; Barach P. …

This commentary discusses recommendations from the Veterans Health Administration on disclosure of medical errors to patients.