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.
Steelman VM, Williams TL, Szekendi MK, et al. Arch Pathol Lab Med. 2016;140:1390-1396.
Errors related to the handling of surgical specimens can lead to serious patient harm in the form of delayed and missed diagnoses as well as repeat procedures. In this retrospective review, researchers looked at 648 reported adverse events and near misses involving surgical specimen management. They found that all steps of the specimen handling process are subject to error, but specimen labeling, collection, and transport represented the most frequently reported incidents. Additionally, 52 of the events led to the need for further treatment or to patient harm. The authors suggest that to enhance the safety of specimen handling, organizations should develop standard processes, provide training for staff, improve communication and handoffs, and consider the use of technological systems that might facilitate tracking of specimens.
Jylhä V, Bates DW, Saranto K. Health Inf Manag. 2016;45:55-63.
This analysis of incident reports found that problems with handling patient clinical information were a common source of preventable adverse events. These incidents were often due to workarounds, such as recording patient information on paper instead of within the electronic medical record.
Shafiq J, Barton M, Noble D, et al. Radiother Oncol. 2009;92:15-21.
Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.
Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.
This study assessed the ability of patients to detect medical errors through an innovative mechanism of using patient safety liaisons (trained patient and family volunteers) to conduct interviews of patients at an outpatient chemotherapy center. Patients' responses to open-ended questions were reviewed by physicians, who classified reported adverse events as adverse events, near misses, or problems with service quality (eg, delays or poor communication). Patients demonstrated good understanding of safe practices in outpatient chemotherapy, and nearly one-fourth of the patients felt they had experienced unsafe care. However, only 1% of the reported events were classified as true medical errors with potential for harm. The vast majority of events related to service quality rather than quality of care. Prior research also assessed the relationship between patient perceptions of care quality and service quality.
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