Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40:1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.
In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Optimal use of health information exchange approaches such as event notification systems may be influenced by organizational capabilities. This study found that healthcare organizations whose positive perceptions of event alerts fit within existing workflows were more likely to use event notification services to improve care coordination and care quality.
Avery AJ, Sheehan C, Bell B, et al. BMJ Qual Saf. 2021;30:961-976.
Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Sundwall DN, Munger MA, Tak CR, et al. Health Equity. 2020;4:430-437.
This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.
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.