Transfusion errors can lead to serious patient harm. In this retrospective analysis of transfusion medical records and related documentation, researchers examined transfusion incident characteristics and logistical errors associated with incidents. Common logistical errors included elevated hemoglobin, inadequate bedside tests, inadequate patient identification, and laboratory errors.

Delayed cancer diagnosis is a major contributor to suboptimal outcomes and malpractice claims. In this review, factors contributing to delayed diagnosis of blood cancers are explored. Initial delays resulted from patients’ non-specific symptoms such as fatigue and symptoms that came and went. After seeking care, factors contributing to delayed diagnosis include seeing a locum general practitioner, being Black or a woman, and having multiple chronic conditions.

Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.

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.

Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).

Wrong blood in tube (WBIT) errors are rare but can lead to complications. One hospital implemented a quality improvement project to reduce WBIT errors with electronic patient identification, manual independent dual verification, and staff education. WBIT errors were significantly reduced and sustained over six years.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review. 

Patients taking oral anti-cancer drugs may experience severe side effects and medication errors. In this randomized controlled study, patients taking oral chemotherapy drugs were randomized to receive usual care (control) or additional intensive pharmacological/pharmaceutical care (intervention). Patients in the intervention group reported considerably fewer medication errors and side effects and increased treatment satisfaction.

Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.

Telehealth benefits, barriers, and challenges have become more apparent due to its increased use during the COVID-19 pandemic. This study evaluated 3,828 telehealth examinations (telephone, email) and found that the incidence of serious or minor adverse events was less than 0.50%.  

Open disclosure of errors and adverse events is increasingly encouraged in health care. This survey of nurses working in oncology settings explored their perspectives about the accuracy of patient-reported errors, use of best-practice disclosure standards by health systems, and the influence of nursing experience on error disclosure. Strategies to overcome barriers should include systems-level approaches, such as regular audits and feedback of patient-reported errors.

Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.

Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.  

Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  

This analysis of transfusion-related safety incident reports found that such events were more commonly reported for pediatric compared to adult patients. This finding could reflect differences in reporting practices or underlying transfusion safety differences. The authors call for continued attention to transfusion safety.

Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.