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This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to uncertainty, bias, and overconfidence that hinder accurate image assessment. Discussing the scope and impact of human error in diagnostic radiology, this book explores the future of advanced information technologies in diagnostic radiology and provides recommendations to reduce the effect of human fallibility on imaging interpretation.

Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.

Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.

"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.

Use of medication administration technologies can reduce transcription errors. This review examined computerized order entry systems, barcode medication administration systems, and other tools that can prevent medication transcription errors.

According to this report, many vendors are still working to add and implement enhanced functions for electronic health records to support medication reconciliation capabilities. Health care workers are instead employing hybrid paper-electronic processes to ensure patients' medication lists remain accurate throughout their hospital stay.

This report highlights findings from 24 AHRQ-funded projects investigating how health information technology can improve clinician decision making, care coordination, and clinical workflow to achieve better outcomes.

Although health information technology (IT) holds great promise for improving patient safety, many of the purported benefits have not yet been realized, and an ever-lengthening list of implementation problems and unintended consequences have been documented. This Institute of Medicine report states that "the current state of safety and health IT is not acceptable" and discusses various safety issues associated with health IT. The report contains a series of recommendations for evaluating and monitoring the safety of health IT, ranging from greater attention to interoperability and human factors engineering in the health IT design process to revisiting the "hold harmless" clause that currently limits health IT vendor liability should systems fail. The Agency for Healthcare Research and Quality recently published an online guide to reducing safety consequences of electronic health records.

This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.

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.

Despite writing almost nothing specifically on health care, clinical psychologist James Reason has influenced modern thinking about medical errors more than any other individual. This book shows why. Although some of the information on error analysis and theory may be too technical for the average reader, Reason’s lucid explanations of complex concepts, his easily accessible examples, and his wry sense of humor make this a must-read for those interested in learning safety theory. His book Managing the Risks of Organizational Accidents is less theoretical and may be more appropriate for the reader interested in an introduction to Reason’s thinking.