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Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

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Isaksson S, Schwarz A, Rusner M, et al. J Patient Saf. 2022;18:325-330.

Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations.

Near miss research in the healthcare system: a scoping review.

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Feng T-ting, Zhang X, Tan L-ling, et al. J Nurs Adm. 2022;52:160-166.

When reported and investigated, near misses provide a unique learning opportunity for individuals and organizations. This scoping review of the literature on near misses identifies contributing factors (organizational, human, and technical); barriers and facilitators to reporting; and quality improvement projects to improve reporting of near misses.

In Conversation With... Remle P. Crowe, PhD

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May 16, 2022

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Identifying Safety Events in the Prehospital Setting

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May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Annual Perspective: Psychological Safety of Healthcare Staff

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March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.

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Andel SA, Tedone AM, Shen W, et al. J Adv Nurs. 2021;78:121-130.

During the first weeks of the COVID-19 pandemic, 120 nurses were surveyed about nurse-to-patient staffing ratios, skill mix, and near misses in their hospitals. Personnel understaffing led to increased use of workarounds, and expertise understaffing led to increased cognitive failures, both of which shaped near misses. Hospital leaders should recognize both forms of understaffing when making staffing decisions, particularly during times of crisis.

A comprehensive departmental care review model: requirements, structure, and flow.

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Nestler DM, Laack TA, Scanlan-Hanson L, et al. Jt Comm J Qual Patient Saf. 2021;47:503-509.

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.

Just culture: the foundation of staff safety in the perioperative environment.

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Fencl JL, Willoughby C, Jackson K. AORN J. 2021;113:329-336.

A just culture balances organizational and individual accountability when a medical error occurs. In a just culture, staff are more likely to report potential patient safety concerns. This commentary defines just culture, describes the critical elements, and provides tools and resources to implement a just culture in the perioperative setting that may increase staff and patient safety.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.

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November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

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Jung OS, Kundu P, Edmondson AC, et al. Jt Comm J Qual Patient Saf. 2021;47:15-22.

Psychological safety can empower health care workers to communicate concerns and improve care. This survey of radiation oncology staff found that near misses are not processed and reported equally. The odds of reporting near misses and events resulting in harm improved with increased psychological safety. The authors conclude that educating health care workers to identify near misses and fostering psychological safety can increase reporting and improve patient safety.

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

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Duffy CC, Bass GA, Duncan JR, et al. J Patient Saf. 2022;18:16-25.

Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

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Kulju S, Morrish W, King LA, et al. J Patient Saf. 2022;18:e290-e296.

Patient misidentification can lead to serious patient safety risks. Researchers used patient safety reports and root cause analyses (RCA) to characterize patient misidentification events in the Veterans Health Administration (VHA). The incidence of patient misidentification in inpatient and outpatient settings was similar and most commonly attributed to the absence of two unique patient identifiers. The authors identified three strategies to mitigate misidentification based on high-reliability principles: (1) develop policies for patient identification throughout the continuum of care, (2) develop policies to report and monitor patient misidentification measures, and (3) apply quality and process improvement tools to patient identification emphasizing use by front line staff.

Patient Safety 101

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September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

The Magnetic Deflection

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May 1, 2019

After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.

Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study.

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Sinclair JE, Austin MA, Bourque C, et al. Prehosp Emerg Care. 2018;22:762-772.

This survey study identified fear of professional consequences as the major barrier for paramedics in voluntarily reporting a patient safety event in the prehospital setting. The authors suggest that improving safety culture is needed in order to increase event reporting.

Developing a reporting culture: learning from close calls and hazardous conditions.

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Sentinel event alert. 2018:1-8.

Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.

Using good catches to promote a just culture and perioperative patient safety.

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Monahan JJ. AORN J. 2018;108:548-552.

The good catch, or near miss, can provide a key learning experience in health care practice. This article discusses the importance of organizational culture in utilizing these experiences as improvement opportunities. The author reviews strategies for nurses to engage in skill development through case review of good catches.

Blame: what does it look like?

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Duthie EA. Nurs Manage. 2018;49:18-21.

A just culture balances organizational context with appropriate accountability after an error. This commentary illustrates the difference between blame and accountability as applied to a near miss. The author highlights how accountability enables individual and organizational learning through constructive examination of error.

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