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Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations.

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Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.

Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.

Defining and studying errors in surgical care: a systematic review.

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Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.

Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

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Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.

Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

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van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;Epub May 18.

Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).

The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide.

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Portland, OR: Oregon Patient Safety Commission; 2022.

Patient falls are common sentinel events. The latest revision of this toolkit shares insights on applying the tenets of root cause analysis to falls investigations.

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

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Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;Epub Aug 2.

Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

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Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 22.

Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

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Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.

Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Patient Safety in the Ambulatory Care Setting

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August 5, 2022

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed.

Criminal liability for nursing and medical harm.

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Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.

Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.

Preventing retained surgical items.

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Weston M, Chiodo C. AORN J. 2022;115:569-575.

Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

Disparities in adverse event reporting for hospitalized children.

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Halvorson EE, Thurtle DP, Easter A, et al. J Patient Saf. 2022;Epub Jul 6.

Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.

Healthcare Safety Investigations Conference 2022.

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September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

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Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;Epub Jul 21.

Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.

Factors influencing medication errors in the prehospital paramedic environment: a mixed method systematic review.

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Walker D, Moloney C, SueSee B, et al. Prehosp Emerg Care. 2022;Epub Jun 27.

Safe medication management practices are critical to providing safe care in all healthcare settings. While there are studies reporting a variety of prehospital adverse events (e.g., respiratory and airway events, communication, etc.), there have been few studies of medication errors that occur in prehospital settings. This mixed methods systematic review of 56 studies and case reports identifies seven major themes such as organizational factors, equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors, and cognitive factors as contributing to safe medication management.

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

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Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;Epub May 25.

Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.

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Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2022;Epub Jul 5.

Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.

Who killed patient safety?

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Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.

This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.

Independent Neurology Inquiry.

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Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

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