Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
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.
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.
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.
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.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Paterson R. Auckland, NZ; Office of the Health and Disability Commissioner: April 2007.
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.
Jones D, Baldwin I, McIntyre T, et al. Qual Saf Health Care. 2006;15:427-32.
Medical emergency teams (METs, also known as rapid response teams) are being widely implemented in U.S. hospitals. Although their effectiveness in preventing adverse patient outcomes is uncertain, a major proposed benefit of such teams is to provide support for nursing staff. This study, conducted at an Australian hospital with a long-standing MET, surveyed ward nurses to determine if they understood the appropriate reasons to call the MET and evaluate if they felt the MET improved patient safety. Nearly all nurses felt the team helped provide more effective care for patients and helped educate nurses in caring for acutely ill patients. Nurses did not feel that they would be criticized for calling the MET. Despite the presence of objective criteria (eg, vital sign abnormalities) for calling the MET, most nurses preferred to use their clinical judgment to decide when to summon the team.
Johnstone M-J, Kanitsaki O. Int J Qual Health Care. 2006;18:383-8.
The authors discuss the importance of understanding the relationship between culture, language, and patient safety and stress that not sufficiently addressing this relationship may put minority patients at risk for adverse events.
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