Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.

The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.

Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.

Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

Identifying barriers and facilitators of medication safety is a patient safety research priority. In this systematic review characterizing the research on medication safety in primary care, researchers found that the majority of studies focused on high-risk populations (such as older adults with polypharmacy) and measured potential harms (such as potentially inappropriate prescribing or potential prescribing omissions) rather than actual harms.

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.

The aim of the Patient Centered Medical Home (PCMH) model is to reorganize primary care services to ensure team-based, coordinated, system-orientation, and accessible care is provided to patients. Using PCMH characteristic data, interviews and surveys with PCMH clinicians, administrators and staff, this study identified four key factors contributing to higher safety culture in PCMHs: (1) leadership in patient safety; (2) reciprocity in advice-seeking; (3) self-efficacy and job satisfaction, and; (4) quality improvement climate. The authors suggest that interventions to improve ambulatory patient safety should focus on leadership and clinician and staff advice-seeking relationships.

This commentary describes how human factors and ergonomics can contribute to the COVID-19 pandemic response, using the example of workflow redesigns in a pediatric ambulatory care clinic.  The authors discuss Just-in-time (JIT) training, adapting workflow processes, identifying potential failure modes and safety hazards, and revisions to protocols and processes to provide safe care to patients during the COVID-19 pandemic.

Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care.  Understanding these barriers and facilitators can guide future endeavors to improve care transitions.

Complex medical therapies such as outpatient parenteral antimicrobial therapy (OPAT), typically performed in acute care hospital, are moving to the home setting, requiring patients and informal caregivers to perform complicated medical tasks. This study sought to describe patient, caregiver, and health care worker’s understanding of their roles in OPAT and barriers to fulfilling these roles. Role ambiguity was a consistent finding in all three groups highlighting the need for enhanced training for people performing these tasks.

Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

This usability study examined whether older adults could use a mobile application to consider the risks and benefits of anticholinergics, a high-risk medication class. The 23 participants reported an overall high usability for the application, suggesting that mobile health information technology has potential to engage patients in safety.

Health care–associated infections are a persistent challenge in all care environments. This commentary explores conditions in long-term care settings that enable infections to spread. The authors recommend applying a human factors engineering model in these settings to reduce risks of infections.

This commentary describes the application of a work system model to discharge transitions as a communication improvement strategy. The authors suggest that human factors approaches be applied to identify potential postdischarge medication safety issues.

Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.

Patient perspectives can identify previously undetected adverse events. This commentary discusses the value of seeking patient insights as an approach to measure medication safety and how such evaluation could affect implementation of meditation safety initiatives. The authors suggest adapting system-oriented approaches to reflect patient-centered concerns.