Reducing or preventing inpatient falls is a common focus of patient safety improvement efforts in hospitals. This study in three orthopedic and three geriatric wards describes multidisciplinary communication about falls prevention strategies. Risk assessments and categorization (e.g., high- or low-risk) were discussed in conjunction with strategies to focus on modifiable risk factors.

Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.

Methadone and buprenorphine are commonly prescribed to treat opioid use disorder, but their use presents patient safety risks. Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care stemmed from errors in dispensing practices (e.g. wrong patient, incorrect dose, incorrect formulation). Staff- and organization-related factors – such as not following protocols, poor continuity of care – contributed to more than half of the incidents.

The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.

Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.

Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.

This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency departments in England and Wales. The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. The authors identified three themes stemming from human factors that contributed to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when indicated), inappropriate response to diagnostic imaging, and failure to order diagnostic imaging. Potential interventions to address these contributors are briefly discussed.

The Institute for Healthcare Improvement's Global Trigger Tool is widely used to identify adverse events. This systematic review found variation in how the tool is implemented, with differing rates of adverse events detected. The authors suggest modifying the trigger tool to capture errors of omission and to assess the preventability of events identified.

… subject of a recent book . … Magrabi F, Liaw ST, Arachi D, Runciman W, Coiera E, Kidd MR. Identifying patient safety …

Incident reporting systems have been widely implemented throughout health care, but mechanisms to respond to reports have received little attention. This commentary provides a framework to use incident reporting to identify, analyze, and address risks.

Providing test results directly to patients is one way in which enhanced patient engagement could improve safety, as failure to appropriately follow up on test results is a recognized cause of diagnostic errors. Accomplishing this will require endorsement from physicians, and this survey examines the attitudes of Australian emergency physicians regarding direct provision of test results to patients. The majority of physicians expressed discomfort with patients having direct access to test results, mainly because physicians feared patients would experience undue anxiety or lack the knowledge necessary to interpret the results. More physicians supported providing patients with direct access to normal test results than abnormal test results, mirroring the findings of a prior survey of primary care providers. Physicians were more supportive of direct release of test results if it would decrease their own workload. The results of this survey reveal the need for careful exploration of the best methods to increase patient engagement without disregarding clinicians' concerns. A previous AHRQ WebM&M interview with Dave deBronkart discussed allowing patients to access their medical records.

Health information technology can both improve patient safety and introduce risks. This analysis examined all safety events associated with the United Kingdom's national program for health information technology. The researchers found that while most events were technical failures, incidents involving human errors had a higher chance of causing harm to patients. Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely to impact care delivery. These results underscore the concerns in prior reports about the unintended consequences of implementing health information technology on patient safety. The findings also lend weight to the Institute of Medicine recommendations that errors related to health information technology be reported and investigated in the United States. A past AHRQ WebM&M perspective explored the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.

Researchers applied change analysis, a type of root cause analysis, to their review of preventable deaths. This method reliably identified contributing factors and enabled more in-depth understanding about underlying problems related to care processes, lending support to utilizing this approach to characterize adverse events and near misses.

A classic British study found that only 5.2% of in-hospital deaths were considered preventable, challenging much higher estimates from prior studies. According to this follow-up investigation, there was little relationship between other measures of safety (such as hospital-acquired infection rates and safety culture perceptions) and the proportion of preventable deaths at the hospital level.

The famous estimate that 44,000 to 98,000 patients die every year in the United States due to preventable adverse events, which was widely publicized in the Institute of Medicine's seminal report, is challenged as a significant overestimate in this British study. The investigators reviewed 1000 randomly selected deaths from 10 hospitals, using a standardized protocol based on prior classic studies of preventable inpatient mortality and found that only 5.2% of deaths were considered preventable. The majority of preventable deaths occurred in patients whose life expectancy was considered to be less than 1 year even if optimal care was provided. As in prior studies, reviewers' agreement on whether a death was preventable was only moderate. The reviewers did find evidence of significant quality problems among both preventable and non-preventable deaths.

This study reviewed nearly 900,000 reports from the FDA Manufacturer and User Facility Device Experience database (MAUDE) and identified 678 reports describing health information technology issues. Investigators uncovered problems with software functionality, system configuration, interface with devices, and network configuration as new categories to the existing classification system.

Although computerized provider order entry (CPOE) systems are being more widely implemented and appear to reduce medication errors, little data exists on the effectiveness of specific CPOE systems. This study evaluated the implementation of two widely used off-the-shelf CPOE systems (with limited decision support) and found that both resulted in significant reductions in serious medication errors. The article also details types of new errors induced by CPOE systems, which, while common, were generally not clinically significant. As the evidence base around implementation of CPOE systems remains relatively small, studies like this that evaluate the real-world performance of information technology are increasingly important.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.

… practitioners about reported patient safety incidents. … Lamont T, Scarpello J. National Patient Safety Agency: …