Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process. 

Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.

Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.

… implementation has been more challenging. Previous WebM&M commentaries highlight the dangers of inadequate medication …

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

This study measured the potential of using Surescripts electronic pharmacy claims data to prevent admission medication history errors among a sample of 70 older patients on complex medication regimens. Accessing this database would likely have prevented at least 35% of these medication reconciliation errors and nearly half of the most severe errors.

Although computerized physician order entry (CPOE) with decision support is considered to be integral to patient safety, high implementation costs and unintended consequences have led to mixed reactions. This cost-utility analysis compared CPOE with paper ordering among patients in acute care hospitals and concluded that CPOE would yield cost savings and improve health outcomes by reducing preventable adverse drug events. The authors noted that high implementation costs, which often exceed prior estimates, significantly decreased the projected cost savings. A related editorial suggests these findings argue conclusively for universal CPOE with decision support, despite the short-term challenges of implementation.

… related to medical information technology in an AHRQ WebM&M interview . …

The impact of clinical decision support systems on improving medication safety has been limited by a lack of standardized and tailored alerts to warn prescribing clinicians about dangerous drug–drug interactions. Progress in this area has stalled owing to disagreement between clinicians and system designers along with concerns about liability if warnings are deployed incorrectly. This study reports on the development of a consensus list of 15 high-severity, clinically significant drug–drug interactions, arrived at through an expert panel approach that included input from pharmacists, physicians, electronic medical record (EMR) developers, and developers of online clinical knowledge bases. The authors recommend that alerts to prevent these interactions should be implemented in all EMRs.

This cost analysis of the 2011 duty hour regulations for resident physicians demonstrates that the regulations will almost certainly result in increased costs for teaching hospitals, unless preventable adverse events decline substantially after the new regulations are implemented.

This study found that physicians generally noted the potential patient safety benefits of an electronic prescribing system, though adoption was adversely affected by perceptions of poor usability.

A recent Institute of Medicine (IOM) report recommended significant changes to resident physicians' work hours to improve patient safety. These recommendations included eliminating extended duration shifts or scheduling nap times during extended shifts, decreasing resident workload, and strictly adhering to the 80-hour weekly work limits originally implemented in 2003. The implementation of the IOM recommendations would cost teaching hospitals approximately $1.6 billion, according to this analysis. However, due to a lack of clear evidence on the safety effects of duty-hour reduction, the authors were unable to accurately estimate the cost savings to society if adverse events were reduced. The accompanying editorial notes the relative lack of evidence supporting additional duty-hour reductions and calls for further study of the relationship between duty hours, handoffs, and patient safety.

Incident reporting (IR) systems serve as an important mechanism to understand, analyze, and potentially prevent errors in the hospital setting, though their utility has been questioned. This study categorized more than 2200 incident reports into whether they described aberrant care processes, undesirable outcomes, or both. Investigators found that 50% were only process-oriented and that these were more useful than solely outcome-oriented reports because the former helped identify preventability and relevant contributing factors. The authors advocate for hospitals to focus their IR systems on process-driven reports that encourage staff to highlight factors amenable to improvement interventions.

Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.

… limitations of their study design may have contributed. … Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous adverse …

Despite mandates for US hospitals to maintain incident reporting systems, little is known about the utility of the data collected. This study linked incident report and discharge databases at two hospitals to examine how frequently reports were filed and what types of incidents were documented. The vast majority of reports were filed by nurses, with less than 2% filed by physicians (a problem noted in prior research). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to procedures. A prior commentary proposed a theoretical framework for using incident reporting data to improve safety.

When medical errors occur, patients desire full disclosure about the error and why it occurred. This qualitative study used focus groups of administrators, resident and attending physicians, and nurses to analyze how practitioners would describe a hypothetical error that caused patient harm. Respondents chose to communicate information about the error in ways that did not always clearly link the error and the adverse clinical outcome, a phenomenon also noted in prior research. The authors propose a formal definition of error disclosure, which incorporates admission and discussion of the error as well as providing sufficient information to "connect the dots" between the error and patient harm.

The researchers assessed specimen labeling errors before and after implementation of three patient safety projects and found that the initiatives reduced labeling errors.