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Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.
Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).
Gandhi TK, Singh H. J. Hosp Med. 2020;15:363-366.
The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.
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.
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.
George D, Hassali MA, Hss A-S. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Grissinger M. P T. 2018;43:645-666.
Although best practices that support safe and reliable medication therapy exist, they are not uniformly embedded in care delivery. This three-part series discusses medication safety risks and highlights topics such as wrong-patient orders, inadequate patient understanding of drug instructions, and poor lighting.
Jeffries M, Keers RN, Phipps DL, et al. PLoS One. 2018;13:e0205419.
Pharmacists enhance medication safety in hospitals and ambulatory settings. The authors interviewed pharmacists about their experience implementing a dashboard that allowed them to identify and provide feedback regarding hazardous medication prescribing in primary care. A WebM&M commentary describes other pharmacy-led efforts to make prescribing safer.
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Toft B. London, UK; Crown Copyright: 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
McDonald CJ. Ann Intern Med. 2006;144:510-6.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-45.
Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.