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1 - 20 of 1598
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.
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;Epub Sep 3.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33(3):mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.
Mikos M, Banas T, Czerw A, et al. Int J Environ Res Public Health. 2021;18(15):8167.
Patient falls resulting in injury are considered a never event. In this analysis of falls within one hospital, rates and trends varied across six clinical departments. The highest rate of falls was seen in rehabilitation and internal medicine, and the lowest rate in orthopedic and rheumatology. Clinical department, rates, and trends should be considered when implementing fall prevention strategies.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.

Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

Leitch S, Dovey S, Cunningham W, et al. BMJ Open. 2021;11(7):e048316.

In this retrospective study, researchers examined patient records to describe patient harm occurring in primary care settings in New Zealand. The majority of harms were minor; 4.5% of harms were considered severe. Nearly 82% of non-fatal harms were considered not preventable and generally arose from routine care.

Academic Medical Center Patient Safety Organization.

Patient Safety organizations (PSO) are in a unique position to educate their members and the larger community on patient safety challenges. This PSO resource collection includes guidelines, papers and alerts drawn from the experiences the membership group to inform action covering topics such as virtual visits and inter-hospital transfers.
Brummell Z, Vindrola-Padros C, Braun D, et al. BMJ Open. 2021;11(7):e046619.
Organizations are expected to learn from failures. The National Health Service Secondary Care Trusts (NSCT) are required to report, learn from, and prevent potentially preventable deaths using the ‘Learning from Deaths’ program. Common action themes include reviewing organizational processes and highlighting appropriate guidelines or protocols. Future research should focus on which actions were most successful at decreasing potentially preventable deaths and disseminating that knowledge.
Khan NF, Booth HP, Myles P, et al. BMC Health Serv Res. 2021;21.
This study assessed how and when quality improvement (QI) feedback reports on prescribing safety are used in one general practice in the UK. Four themes were identified: receiving the report, facilitators and barriers to acting upon the report, acting upon the report, and how the report contributes to a quality culture. Facilitators included effective dissemination of reports while barriers included lack of time to act upon the reports. As most practitioners indicated the QI reports were useful, efforts should be made to address barriers to acting upon the reports.
Langevin M, Ward N, Fitzgibbons C, et al. Simul Healthc. 2021;Epub Jun 18.
Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of error as well as generate creative strategies for error prevention. In this study, researchers found that simulation can optimize SBEA-generated recommendations and that it provides opportunity to test the intervention in real-life settings before widespread implementation.
Nestler DM, Laack TA, Scanlan-Hanson L, et al. Jt Comm J Qual Patient Saf. 2021;47(8):503-509.
Peer review can provide clinicians an opportunity to learn from failure, but the process has yet to be standardized.  This article describes the development and implementation of an evidence-based, structured, reproducible care review system at one emergency department affiliated with an academic hospital. The authors outline the care review process, which includes direct care staff feedback; single provider and peer review; structured case rating; systems analysis; loop closure; practice and education output; and consideration of psychological safety.

The Society for Post-Acute and Long-Term Care Medicine.

Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning network to share aggregated data, lessons learned, and educational opportunities to reduce medication adverse events through safe deprescribing. 

Cifra CL, Westlund E, Ten Eyck P, et al. Diagnosis (Berl). 2021;8(2):193-198. doi: 10.1515/dx-2020-0023.

Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.
Harms-Ringdahl L. Safety. 2021;7(1):19.
The primary purpose of incident reporting and analysis is to propose safety reforms. This study reviewed three sets of event investigations (one from industrial companies and two from hospitals) using two methods of investigation (in-depth or root cause analysis). In-depth analysis resulted in more suggestions for reform targeted at the federal, regional, health system, or department level. Root cause analysis resulted in suggestions at the department or ward level. The authors conclude there is room for improvement in  in the management and performance of event investigations in the healthcare sector.

An essential aspect of preventing medical errors and improving patient safety is using data effectively to understand, track and communicate performance on patient safety metrics. This primer provides an overview of visual tools – histograms, scatter plots, run charts and control charts – hospitals and health systems can leverage to track patient safety data.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication. The program reduced overall medical errors, along with the incidence of several specific types of mistakes, including aspiration pneumonia (caused by entrance of foreign materials into the bronchial tree) and errors during management of shock.