Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
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.
Manias E, Bucknall T, Hughes C, et al. BMC Geriatr. 2019;19:95.
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.
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.
Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36:316-324.
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;24:1874-1884.
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.
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.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Klim S, Kelly A-M, Kerr D, et al. J Clin Nurs. 2013;22:2233-43.
In this mixed-methods study of nursing handoffs in the emergency department, 96% of participants felt that they received adequate information. Participating nurses believed that the essential data included demographics, presenting problems, nursing observations, and future care plans.
Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-33.
Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
Cunningham FC, Ranmuthugala G, Plumb J, et al. BMJ Qual Saf. 2012;21:239-49.
Establishing a culture of safety is an essential component of improving safety within an organization. Analysis of programs that have successfully stimulated innovation to tackle safety issues, such as the Keystone ICU project or Kaiser Permanente, have found that a critical aspect of their success has been understanding the dynamics of how groups of professionals work together. This review explores how social network analysis—a method of examining relationships in complex systems, and how these relationships influence dissemination of knowledge and innovation—has been utilized to develop health professional networks for improving quality and safety. With the growing recognition of the role of context in determining the success of patient safety efforts, social network analysis provides an important tool for developing organizational approaches to improving safety.
Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-40.
Poor care coordination has been shown to be a risk factor for preventable errors in the ambulatory setting, and patients consistently voice concern about care coordination problems. This survey, which builds on prior Commonwealth Fund reports, found that care coordination was a major determinant of patient-reported medication errors in all seven countries studied. The study reinforces the role of health systems in ambulatory patient safety, and the need for improved communication between providers and better integration of health systems to reduce preventable errors for outpatients.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.
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