This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

Engaging patients and families in patient safety efforts and encouraging them to speak up about concerns is an ongoing healthcare priority. Based on narrative interviews with people raising and responding to concerns and complaints in six English National Health Service (NHS) organizations, this study explored how substandard responses to concerns and complaints can lead to organizational failures.

Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.

This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.

Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.

This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.

Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.

This study used vignettes to assess clinicians' perception of patient engagement in safety efforts. The authors found that while clinicians generally supported such interventions, they had the potential to harm the clinician–patient relationship.

Communication, coordination, and cooperation are key elements to effective teamwork, especially during high-stakes situations. This simulator-based study observed trauma teams and found that proven techniques, such as closed-loop communication, occurred infrequently, even in teams that had previously completed teamwork training programs.

The academic year-end transfer of primary care patients from graduating residents to their successors can pose risks to patients. This survey of patients within an academic primary care practice identifies the concerns patients have with the transfer process and the barriers in care they encounter as a result.

Black and brown women experience longer delays in receiving a breast cancer diagnosis and increased morbidity and mortality following diagnosis as compared with white women. Women who recently received abnormal screening mammograms were interviewed about their experiences with follow-up. Women who experienced delayed follow-up care reported dissatisfaction with communication of results; perceived disrespect, logistical barriers; anxiety and fear about a possible cancer diagnosis; and a lack of information about breast cancer screening and symptoms.

This commentary uses two medication error reporting failures to provide insight into the social and cultural factors that influence incident reporting.