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Cierniak KH; Gaunt MJ; Grissinger M.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Ford EC, Smith K, Harris K, et al. Med Phys. 2012;39:6968-71.
Analysis of voluntarily reported errors in radiation therapy treatments resulted in systematic changes to treatment planning and delivery. After the system improvements were implemented, no similar errors occurred and multiple near misses were detected before patients were affected.
Kaushal R, Goldmann DA, Keohane CA, et al. BMJ Qual Saf. 2010;19.
Pediatric medication errors are common yet studied less in the ambulatory setting than in the inpatient arena. This prospective cohort study of six outpatient practices identified more than 1200 medication errors with minimal potential for harm, and more than 460 potentially harmful ones deemed near misses. Overall, a remarkable half of all prescriptions had errors and a fifth of those had potential for harm. The authors were particularly interested in understanding the differences between errors with minimal potential for harm and near misses. The prescribing stage was responsible for nearly 95% of the errors in the former category but only 60% of the latter. Whereas inappropriate abbreviations were the most common cause in the minimal harm group, dosing errors were most common in the near misses. Their findings suggest that e-prescribing may effectively address many of the issues identified, particularly around provider illegibility, but further solutions will also be needed.
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.
Shaw R. Quality and Safety in Health Care. 2005;14.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.