… and failure to communicate effectively. … Burrus  S, Hall M, Tooley E, et al. Factors related to serious safety …

High-reliability organizations have developed methods for achieving safety despite hazardous conditions. This review summarizes the systems science, organizational structure, and interpersonal working methods that enable high-risk industries like health care to practice reliably and learn from mistakes.

Patient safety has been described as an unmet need in physician training. This commentary describes the development and implementation of a patient safety curriculum in a pediatric primary care practice and the results of the program.

This survey of otolaryngologists found very little overall progress in self-reported patient safety errors compared with a similar survey in 2004. For instance, wrong-site surgeries continue to occur despite garnering major attention over the past decade and being classified as a never event.

This study leveraged a multicenter collaborative approach to address the complex process of managing acute patient deteriorations. The authors conclude that wide-scale improvements take time, but the collaborative approach can accelerate such goals and foster a culture of safety.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

A novel trigger tool intended to detect errors in pediatric otolaryngology patients unfortunately missed many cases of preventable adverse events.

This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.

This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.

… AORN Journal … AORN J … This commentary describes how one …

Retrospective chart review identified many errors (primarily in documentation) among pediatric otolaryngology inpatients but no major morbidity or mortality.

This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.

Diagnostic errors in pediatric echocardiography were infrequent, but generally were severe enough to change patient management, and were mostly considered preventable.

The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) have been widely used to identify patient safety events in adult populations. Pediatric-specific PSIs have recently been developed as well. This study used PSI data from more than 400,000 pediatric hospital admissions to estimate the impact on costs and hospital length of stay associated with inpatient adverse events. These data provide the first estimate of the economic impact of preventable adverse events in children's hospitals. Based on similar research in adults, the Centers for Medicare and Medicaid Services recently decided to stop reimbursing hospitals for costs associated with certain adverse events.

This report reviews potential fire sources, provides guidelines to prevent and reduce harm from operating room fires, and describes fire response protocols.

The investigators surveyed otolaryngologists regarding errors and found that the otolaryngologists disclosed mistakes to their patients, experienced emotional reactions, and took corrective actions.

The authors assessed the literature specific to errors and adverse events in the practice of otolaryngology, summarize the findings, and suggest future actions to manage errors in their specialty.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.