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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.
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.
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
Cohen MR. Hosp Pharm. 2008;43(4):257-260.
This monthly selection includes reports of a near miss when using a medication-reconciliation form as an order sheet, epidural tubing mistakenly utilized for an intravenous medication, a topical medication given orally, and problems with monitoring temperatures of medication refrigerators.
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.