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Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

The physical design or layout of a clinical space can affect patient safety.  This mixed-methods study of 8 ambulatory oncology offices found that the physical layout (e.g., visibility of patients during infusion) and location (i.e., proximity of infusion center to prescribers) impacted communication and patient safety. Consultation with clinicians regarding the physical environment prior to design of ambulatory oncology clinics could improve communication and therefore patient safety.

This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.

Research into patient safety culture in primary dental care remains limited. This commentary provides an overview of patient safety in dentistry and tools to develop a robust patient safety culture, including human factors and supporting second victims.

Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.

The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.

Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.

Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.

Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.

High reliability organizations have developed methods for achieving safety despite hazardous conditions. In this systematic review, the authors summarize the five “hallmarks” of high reliability organizations (preoccupation with failure; reluctance to simplify interpretations; sensitivity to operations; commitment to resilience; and deference to expertise). The authors also discuss generalizable interventions that can guide systems towards high reliability - process redesign, training, and organization redesign.

The COVID-19 pandemic has resulted in the delivery of anesthesia outside of operating rooms, such as in emergency departments, intensive care units, and makeshift field hospitals. This review examines challenges in maintaining patient safety while providing anesthesia services in nontraditional operating room environments.