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Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Hada A, Coyer F. Nurs Health Sci. 2021;23(2):337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 
Thomas J, Dahm MR, Li J, et al. Health Expect. 2021;24(2):222-233.
Missed or failure to follow up on test results threatens patient safety. This qualitative study used volunteers to explore consumer perspectives related to test result management. Participants identified several challenges that patients experience with test-results management, including systems-level factors related to the emergency department and patient-level factors impacting understanding of test results.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18(8):3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Leamy K, Thompson J, Mitra B. Australas Emerg Care. 2019;22:221-226.
This article reports the results of a prospective pre-post interventional study undertaken to determine whether providing a simplified information card to patients (in addition to discharge summaries) upon discharge from Australian emergency departments would improve patient awareness of their diagnosis and follow-up requirements. Brief interviews conducted with 112 pre-intervention study participants and 117 who received the short discharge card, indicated statistically significant improvement (73.2% to 89.7%, p<0.001) in patient awareness with the short discharge card. 
Manias E, Bucknall T, Hughes C, et al. BMC Geriatr. 2019;19(1):95.
Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, including managing changes to their medications. This systematic review suggests that there is significant opportunity for health care providers to improve family engagement in managing medications of elderly patients during care transitions.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Almanasreh E, Moles R, Chen TF. Br J Clin Pharmacol. 2016;82(3):645-658.
Accurate medication reconciliation has been shown to improve patient safety across multiple care settings, yet barriers to implementation persist. This systematic review found significant variation across studies in how medication discrepancies were identified and classified. Researchers suggest that the use of a standardized taxonomy would better facilitate efforts to mitigate medication discrepancies and improve patient safety.
Redley B, Bucknall TK, Evans S, et al. Int J Qual Health Care. 2016;28:573-579.
Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.
Mekonnen AB, McLachlan AJ, Brien J-AE. J Clin Pharm Ther. 2016;41(2):128-144.
Medication reconciliation was initially established as a National Patient Safety Goal in 2005. This systematic review included 19 studies that supported the positive impact of pharmacy-led medication reconciliation on decreasing discrepancies during hospital admission and discharge.
Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36(5):316-324.
This study used root cause analysis to identify underlying causes of suicide among mental health service clients. Researchers found that most patients had denied suicidal ideation and had missed follow-up in their mental health care. Their results underscore the challenge of preventing suicide in patients with mental illness.
Braaf S, Riley R, Manias E. J Clin Nurs. 2015;24(13-14):1874-1884.
This qualitative study of communication among providers in perioperative care revealed a reliance on written documentation, which was often difficult to find or missing key information, rather than verbal signout. This finding underscores the importance of structured, verbal handoffs to ensure adequate provider communication.
Gardiner TM, Marshall AP, Gillespie BM. Aust Crit Care. 2015;28:226-34.
Structured information transfer can reduce communication errors and augment the handoff process. Exploring standardized handovers between the operating room and the intensive care unit, this commentary found the evidence base to be limited and calls for more studies to expand the understanding of how structured communication methods affect postoperative handover.
Callen J, Giardina TD, Singh H, et al. J Med Internet Res. 2015;17:e60.
Providing test results directly to patients is one way in which enhanced patient engagement could improve safety, as failure to appropriately follow up on test results is a recognized cause of diagnostic errors. Accomplishing this will require endorsement from physicians, and this survey examines the attitudes of Australian emergency physicians regarding direct provision of test results to patients. The majority of physicians expressed discomfort with patients having direct access to test results, mainly because physicians feared patients would experience undue anxiety or lack the knowledge necessary to interpret the results. More physicians supported providing patients with direct access to normal test results than abnormal test results, mirroring the findings of a prior survey of primary care providers. Physicians were more supportive of direct release of test results if it would decrease their own workload. The results of this survey reveal the need for careful exploration of the best methods to increase patient engagement without disregarding clinicians' concerns. A previous AHRQ WebM&M interview with Dave deBronkart discussed allowing patients to access their medical records.
Lee H, Cumin D, Devcich DA, et al. J Adv Nurs. 2015;71:160-8.
This educational experiment randomized nurses to view varying versions of handoff videos. In the recorded handovers, information was transferred either as a simple statement, as spoken information that conveyed concern, as a simple statement with a written summary, or verbally with expressions of concern and a written summary. Researchers found that these factors (expressing concern or referring to a written summary) did not affect information retention, suggesting that other approaches, including standardized communication, may be more useful to improve handoffs.
Boyd M. J Eval Clin Pract. 2015;21:461-9.
Although recommended as a patient safety improvement strategy, the value of root cause analysis has been debated. This commentary suggests a three-step approach for optimizing root cause analysis results to detect factors that contribute to adverse events. The author applies philosophical principles to identify and prioritize interventions to enhance benefit from root cause analysis.
Investigators CMETIS, Cheung W, Sahai V, et al. Med J Aust. 2014;201:528-31.
Rapid response teams, while controversial, have become a mainstay of hospital efforts to identify patients at risk for acute deterioration. This survey of rapid response members, including physicians and nurses, sought to determine whether team activities adversely affected usual work responsibilities. Although there were no reports of patient harm associated with attending rapid response events instead of normal duties, team members did report significant disruption of usual routines and inconvenience to other staff and patients. Hospital incident reporting systems did not capture this unintended consequence of rapid response mobilization. These data add to the concerns about rapid response teams as a patient safety strategy. A past AHRQ WebM&M perspective covers lessons learned from early rapid response system implementation.
Boyd M, Cumin D, Lombard B, et al. BMJ Qual Saf. 2014;23:989-93.
Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.