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.

Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.

Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.

Previous studies have investigated the benefits of unit-based interventions as a potential safety strategy. This survey study sought to examine implementation of several unit-based initiatives to improve care quality in inpatient settings: localization of physicians to specific designated units, nurse–physician joint leadership, periodic review of local performance data, and interdisciplinary rounds. Investigators invited residency program directors and hospital medicine leaders to participate in the study. The response rate was low and thus the findings may not reflect academic hospitals in general. Overall, among respondents' institutions, the interventions were not widely or consistently implemented. These findings underscore the challenge of translating interventions shown to be effective for enhancing safety in research settings into clinical practice.

Patients may provide valuable insights into potential safety problems. This study describes the development and initial validation of a survey tool for capturing patient feedback about safety in the ambulatory setting. This tool expanded the previously developed patient measure of safety questionnaire to include four primary care–specific domains: continuity of care, external policy context, primary–secondary interface, and referrals. The survey was developed by an expert panel through a modified Delphi process and was well received by patients and staff during face validity testing. This tool aims to provide patient perspectives to primary care organizations to focus improvement efforts in these settings. A prior AHRQ WebM&M interview discussed the emerging field of ambulatory patient safety.

The patient safety field's understanding of safety issues in ambulatory care continues to evolve. Recent studies have helped quantify the incidence of diagnostic errors and medication errors in primary care, indicating that serious safety concerns exist in this arena. This Australian study used qualitative methodology to examine patient and caregiver perceptions of factors affecting safety in ambulatory care. The investigators identified several unique themes related to safety, including difficulties in accessing care, insufficient continuity of care, and poor communication between primary care physicians and specialists. Some of these themes were also found in a prior study of primary care patients in the United Kingdom. The emerging area of ambulatory patient safety was explored in a previous AHRQ WebM&M perspective.

Although workarounds may be essential to effective care delivery in some instances, they also pose significant risks to patient safety. This systematic review of nursing workarounds builds upon a similar study. The article includes illustrative examples of both individual and collective workarounds, as well as the potential effects in acute care settings for patients, staff, and organizations. The authors conclude that the research on nursing workarounds has been heterogeneous and "relatively underdeveloped." A previous AHRQ WebM&M perspective discussed workarounds on the front lines of health care.

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.

… and intra-hospital handoffs. … Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to …

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.

This survey of geriatric patients, conducted 2 weeks after hospital discharge, identified a large proportion who suffered problems with their care after discharge. The primary care physician was unaware of the hospitalization for nearly one-third of patients, and those patients reported significantly more concerns about their care.

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

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.