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Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.

Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.

High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  

The author defines ‘work debate spaces’ as organizational spaces that serve as a vehicle for organizational learning, practice changes, and performance improvement. This article discusses the role of formal and informal ‘work debate spaces’ in establishing a culture of safety in critical care settings. Examples of formal and informal spaces include mortality and morbidity (M&M) meetings (formal) and handoffs between shifts (informal).

This scoping review assessed 44 studies to describe the scope of the evidence of the impact of missed, rationed and unfinished nursing care on patient-related outcomes; 9 of these studies focused on the impact on patient safety outcomes. The review concludes that medication errors as the biggest threat to patient safety resulting from missed, rationed or unfinished care, and that falls (with or without injury) and hospital-acquired infections are the most common resulting adverse events. These adverse events are attributed to the omission of preventive nursing care activities, such as handwashing, patient education and maintaining a safe environment.

Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

This study reviewed incident reports involving older adult patient transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved and whether reports included any evidence of individual or organizational learning.   Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure injuries, falls, medication, and documentation errors. Few incident reports referenced individual or organizational learning (e.g., team discussions, root cause analysis) to inform practice or policy changes. A prior WebM&M describes a medication error occurring during an intrahospital transfer between the ICU and interventional radiology.  

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors.