Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.

Patient safety investigations hinge on the expertise and experiences of the investigator. This commentary discusses the ways in which cognitive biases can impact patient safety investigations and identifies potential mitigation strategies to improve decision-making processes.

“Opioid never event” (ONE) is a proposed classification to describe dependence or overdose among opioid-naïve patients prescribed opioids at hospital discharge. Based on a retrospective review of medical records of patients at one academic medical center, researchers estimated that the ONE affected approximately 2 per 1,000 opioid-naïve surgical patients and persistent opioid use 90 to 360 days after surgery was present in 45% of patients with ONEs.

Physicians, including resident physicians, report safety events at lower rates than nurses and other staff. This study analyzed adverse event and near miss reporting by residents in one American hospital. Although pathology residents accounted for more than 5% of residents in the hospital, they only accounted for 0.5% of all reports.

Nurses are responsible for several steps in the medication-use process, including preparation, administration, and monitoring of most medications. This study queried nurses working at a 10-hospital system in the southeastern United States about their attitudes, beliefs, and skills surrounding medication safety and error reporting. Survey responses indicate that nurses felt comfortable completing an incident report regarding an error and disclosing the error to another health care provider. There was some ambiguity around rating the severity of hypothetical errors.

Research has shown wide variation in error reporting by profession, with nurses reporting substantially more often than physicians. This study explored not only report rates by profession, but also across departments and event types. Results indicate physicians and technicians are more likely to report errors from across departmental boundaries , while nurses and physicians report a wider variety of error types.

Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.

Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.

Reporting incidents and errors is a cornerstone of patient safety improvement efforts, but challenges remain, including low quality of reports and low rates of reporting. This article discusses the technological challenges of incident reporting and offers recommendations to improve usability in future reporting systems.

Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations. 

Adverse event reporting is foundational to improving patient safety, but many events go unreported. This review identified four key priorities in increasing adverse event reporting: understanding and reducing barriers; improving perceptions of adverse event reporting within healthcare hierarchies; improving organizational culture; and improving outcomes measurement.

Reporting medication errors and near misses should be taught to prelicensure nursing students but is not always included in nursing programs. This quality improvement project focused on the near-miss medication error reporting by student nurses. The authors found that dosing errors were 81% of the incidents, but there were multiple contributing factors including communication, competency and education, environmental and human limitations, and policies and procedures. The findings can be helpful to other nursing programs to refocus education on medication errors to areas were students have problems.

Studies have shown that physicians are less likely to report errors and adverse events when compared to other clinicians. To increase the number of self-reports by surgeons, this hospital implemented a program of financial incentives. The incentive program led to an increase in reporting by physicians and physician assistants.

Workplace violence in health care settings can adversely affect the safety of healthcare workers and patients. Baseline responses from 309 pediatric physicians, nurses, and residents at one hospital revealed that the majority have received verbal threats from patients or family members. Offensive behavior from patients or family members was commonly based on provider age, gender, race/ethnicity, or appearance. After an interprofessional training intervention focused on addressing and reporting mistreatment, providers reported increased reporting knowledge, self-efficacy, and reporting behaviors.

Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.

Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.