Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.

TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.

Incomplete communication regarding patient information can diminish the safety of care delivery. This commentary describes how a quality improvement project applied plan–do–study–act cycles to enhance collection of patient data. Researchers developed, tested, and refined a ward round template in a United Kingdom urology service and increased compliance in the recording of patient care measures.

This analysis of national hospital data found that while odds of overall mortality from urological surgery decreased, failure to rescue increased over time, with lower-income, older aged, and ethnic minority patients as predictors for higher risk. This work emphasizes the need to examine disparities in patient safety outcomes.

The increasing technological sophistication of hospital care has led to greater appreciation of the potential safety hazards posed by medical devices. This observational study used the AHRQ Patient Safety Indicators to examine whether the introduction of a new medical device, the da Vinci robot, led to a change in surgical processes or surgeon performance for a specific procedure, radical prostatectomy. The authors found that during initial adoption of the new technique and device, there was an increased risk of unsafe practice compared with the standard method of conducting radical prostatectomy. This finding emphasizes the need to create safety processes and monitoring when novel devices and procedures are introduced, given that voluntary reporting underestimates safety problems related to devices. A recent AHRQ WebM&M perspective discusses the challenges associated with ensuring medical device safety in the complex health care environment.

This study reviews published data on the incidence of errors in minimally invasive surgery and proposes a classification scheme for such errors based on the classic systems approach.

For many types of cancer, the extent of disease at diagnosis (i.e., the stage of the disease) predicts the ultimate prognosis. However, this analysis of patients newly diagnosed with prostate cancer found that clinicians erred in determining the clinical stage in more than one-third of cases. Overreliance on physical examination results, underemphasis of imaging results, and inappropriate application of biopsy results all appeared to contribute to misdiagnosis. Diagnostic errors have also been documented in the pathologic diagnosis of cancer.

This study found that inadequate training and supervision of medical students and interns contribute to preventable urinary catheterization injuries.

A post-surgical complication experienced by one of the authors—himself a patient safety researcher—is examined in detail using root cause analysis.

Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.

Approximately 1 in 300 male patients at this university hospital experienced a urethral injury due to urinary catheter placement. A nursing education program significantly reduced the risk of injury.

This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.

This study discovered that more than 25% of indemnity payments from closed malpractice claims resulted from missed or delayed diagnoses.

The researchers observed a urology surgery team to measure the frequency and source of interruptions in the operating theater.