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Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

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Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.

Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

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Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic.

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Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.

This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

Patient Safety.

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Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Safety, Equity and Engagement in Maternity Services.

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Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation.

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Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey

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Stahl K, Groene O. PLoS ONE. 2021;16:e0259252.

Patient safety in ambulatory care is an emerging focus of measurement and improvement efforts. This cross-sectional study including patients from 22 ambulatory care practices in Germany found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors discuss how different approaches to voluntary reporting can influence measurement of patient experience.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

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Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2021;Epub Nov 18.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Complaints to the Parliamentary and Health Service Ombudsman.

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London, UK: Parliamentary and Health Service Ombudsman.

The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication series provides information about complaints submitted to trusts to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

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Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71:e931-e940.

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

The aspects of healthcare quality that are important to health professionals and patients: a qualitative study.

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Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2022;105:1561-1570.

In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

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Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21:618.

Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.

How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sectional telephone survey.

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Seufert S, de Cruppé W, Assheuer M, et al. BMJ Open. 2021;11:e052973.

Patient reports of patient safety incidents are one method to detect safety hazards. This telephone survey of German citizens found that patients frequently report patient safety incidents back to their general practitioner or specialist and these incidents can lead to loss of trust in the physician.

The second victim: a contested term?

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Tumelty M-E. J Patient Saf. 2021;17:e1488-e1493.

There has been some controversy around the term ‘second victim.’ Based on qualitative interviews with representatives of medical training organizations and legal professionals in Ireland, this study found that the use of term ‘second victim’ can be seen as insensitive to the patient and can erode the professional identity of the healthcare provider.

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

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McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.

Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.

SECUre: a multicentre survey of the safety of emergency care in UK emergency departments.

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Flowerdew L, Tipping M. Emerg Med J. 2021;38:769-775.

This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

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Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18:9206.

Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

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Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2022;44:196-205.

Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.

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