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Lindblad M, Unbeck M, Nilsson L, et al. BMC Health Serv Res. 2020;20:289.
This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2020;29:103-112.
This retrospective study of cancer care safety examined the extent to which patients received recommended chemotherapy. A significant proportion of breast, lung, and colorectal cancer patients did not receive chemotherapy; patients who were black and those lacking health insurance or covered by Medicaid were at higher risk. There was marked variability in chemotherapy delivery by location and hospital. The authors conclude that failure to administer chemotherapy is a significant safety gap that should be addressed.
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.
Redmond P, McDowell R, Grimes TC, et al. BMJ Open. 2019;9:e024747.
This retrospective cohort study of patients age 65 and older on chronic medications found that unintentional medication discontinuation does occur following hospitalization. As with prior studies, medication documentation in hospital discharge summaries remains highly variable.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Grant S, Guthrie B. Soc Sci Med. 2018;203:43-50.
Past studies have explored the impact of nurse and clinician workload on the quality of care. In this study, researchers examined how general practitioners and administrative staff across eight United Kingdom practices work together to fill prescription requests and manage test results.
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Dolejs SC, Janowak CF, Zarzaur BL. Am Surg. 2017;83:780-785.
Despite the widespread adoption of health information technology, medication errors remain a significant source of patient harm. This study found that medication errors in trauma patients were more common among those who were severely injured and who remained in the hospital for a longer amount of time.
Lane SJ, Troyer JL, Dienemann JA, et al. Health Care Manag Rev. 2014;39:340-351.
According to this study, dose omissions were the most common medication errors occurring during transitions to nursing home care. However, the wide range of errors detected suggests that multifaceted interventions would be needed to improve medication safety. A prior AHRQ WebM&M interview and its accompanying perspective discuss safety in nursing homes.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.
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.