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1 - 20 of 43

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.

Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is part of a publication series examining diagnostic improvement across health care.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health. May 20, 2021.

Magnetic resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process missteps occur. This report shares assessment steps to assure that medical devices are labeled appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems encountered when testing device use.

Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.

Challenges beset safe care delivery for indigenous peoples. This report examines factors contributing to adverse events in this patient population. Recommendations for improvement include an emphasis on harm monitoring and incident reporting. A related report examines the lack of application of maternity best practices in the Indian Health Service.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11.

Incomplete assessment of patient needs can miss opportunities to prevent patient harm. This report analyzes an incident where an intoxicated patient called a dedicated crisis support line yet preventive measures weren’t activated to avert an accidental overdose resulting in patient death. Recommendations for improvement include enhanced training for weekend and holiday staff, standardized safety plan development, and systemized internal review processes.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   

Cumberlege J. London, England, Crown Copyright. July 8, 2020.

Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.

James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.

Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.
Farnborough, UK: Healthcare Safety Investigation Branch; 2019.
Design flaws and improper use of technologies that transfer medication and prescription information between provider environments is a known threat to patient safety. This report analyzes an anticoagulant overdose incident and found that information technology missteps contributed to the error.
Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-650.
One strategy to reduce the potential of opioid misuse is to limit access to unused medications in the home. Examining programs to safely collect unused prescription opioids for disposal and patient awareness and use of such programs, this report found that many adults are unaware these programs exist or choose to retain or sell unused prescription opioids rather than utilize safe disposal services.