This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Steelman VM, Williams TL, Szekendi MK, et al. Arch Pathol Lab Med. 2016;140:1390-1396.
Errors related to the handling of surgical specimens can lead to serious patient harm in the form of delayed and missed diagnoses as well as repeat procedures. In this retrospective review, researchers looked at 648 reported adverse events and near misses involving surgical specimen management. They found that all steps of the specimen handling process are subject to error, but specimen labeling, collection, and transport represented the most frequently reported incidents. Additionally, 52 of the events led to the need for further treatment or to patient harm. The authors suggest that to enhance the safety of specimen handling, organizations should develop standard processes, provide training for staff, improve communication and handoffs, and consider the use of technological systems that might facilitate tracking of specimens.
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.
This study assessed the ability of patients to detect medical errors through an innovative mechanism of using patient safety liaisons (trained patient and family volunteers) to conduct interviews of patients at an outpatient chemotherapy center. Patients' responses to open-ended questions were reviewed by physicians, who classified reported adverse events as adverse events, near misses, or problems with service quality (eg, delays or poor communication). Patients demonstrated good understanding of safe practices in outpatient chemotherapy, and nearly one-fourth of the patients felt they had experienced unsafe care. However, only 1% of the reported events were classified as true medical errors with potential for harm. The vast majority of events related to service quality rather than quality of care. Prior research also assessed the relationship between patient perceptions of care quality and service quality.
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