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1 - 20 of 133

de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.

The global effect of harm associated with preventable drug errors is substantial. This report discusses the human and financial impact of medication errors in a variety of countries, prescribing process improvement, established efforts to enhance medicine use safety, and avenues for national medication safety achievement.

US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.

Problems with clinician order delivery can result in harmful care delays. This report discusses how an electronic health record (EHR) system sent thousands of requests for medical care in a large health system to no location rather than to the intended site for care. These misattributions contributed to 142 patient safety events. The analysis highlighted factors contributing to the EHR misdistribution of orders and shared concerns that the organization’s approach to reduce the risk for misrouted orders lacks effectiveness.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.

Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.

Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021. 

The emergence of telemedicine during the COVID-19 pandemic has situated it to become an accepted model for health service provision despite safety concerns. This white paper discusses a 6-item framework to enhance the safety, equity, and person-centeredness of telemedicine and recommendations for embedding safer methods into telemedicine practice.

Farnborough, UK: Healthcare Safety Investigation Branch; February 2, 2022.

Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing, and administration accuracy. This report examines factors contributing to a computation mistake that resulted in a child receiving a 10-fold anticoagulant overdose over a 3-day period. Areas of focus for improvement include use of prescribing technology, and the double-check as an error barrier.
Horsham, PA: Institute for Safe Medication Practices; 2022.
This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summarizes ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National Academies Press.

Primary care is the starting point for safe, equitable health care. This report outlines a system-focused implementation framework to enhance person-centered, accessible primary care. The approach aims to a focus on generating accountability through payment reform, multi-disciplinary team development, workforce support, and digital health utilization.

Evanston, IL: Society to Improve Diagnosis in Medicine; March 2021.

Telehealth is commonly used to deliver health care, yet its safety across the continuum has yet to be determined. This report highlights perspectives on the potential of telediagnosis and examines its reach, effectiveness, adoption, implementation, and maintenance, to inform actions to ensure its safe use.

Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 20(21)-0040-4-EF.

Health information technology (Health IT) presents opportunities to engage patients and families in decision making. This issue brief highlights health IT tools that can close this communication gap to engage patients in diagnosis in the emergency room. This brief is part of a publication series examining diagnostic improvement across health care.