McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99:693-707F.
Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.
Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11:e256-e262.
Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
Shaikh U, Natale JAE, Till DA, et al. Pediatr Emerg Care. 2022;38:e283-e286.
Incident reporting systems may be underutilized by medical trainees. This article describes a brief, interactive simulation activity to improve identification and reporting of patient safety hazards among medical students and interns.
COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382:2514-2523.
This multicenter cluster randomized trial explored the impact of eliminating extended-duration work schedules (shifts in excess of 24 hours) on serious medical errors made by residents in the pediatric intensive care unit (ICU). The authors found that residents in ICUs which eliminated extended shifts in favor of day and night shifts of 16 hours or less made significantly more serious errors than residents assigned to extended-duration work schedules. The authors observed that the resident-to-patient ratio was higher during schedules which eliminated extended shifts, but also that these results might have been confounded by concurrent increases in workload in ICUs eliminating extended shifts.
Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.
Dunn WF, Adams SC, Adams RW. Chest. 2008;133:1217-20.
This case report describes how diagnostic and medication errors led to a temporary coma. The article features the views of both the patient and her husband, and an accompanying editorial discusses disclosing errors to patients.
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.
Shaw R. Quality and Safety in Health Care. 2005;14.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.