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April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

Pediatric trainee perspectives on the decision to disclose medical errors.

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Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.

Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

A family and hospital's journey and commitment to improving diagnostic safety.

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Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.

The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; February 2022.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2021 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 34 percent of the time.

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Medical Office Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

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Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.

Considering the safety and quality of artificial intelligence in health care.

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Ross P, Spates K. Jt Comm J Qual Patient Saf. 2020;46:596-599.

This article discusses healthcare safety and quality issues in artificial intelligence (AI) development and use (such as biases in AI tools) and approaches to increase transparency and understanding of AI tools among health care providers.

"We're not ready, but I don't think you're ever ready." Clinician perspectives on implementation of crisis standards of care.

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Chuang E, Cuartas PA, Powell T, et al. AJOB Empir Bioeth. 2020;11:148-159.

Before the emergence of COVID-19, the National Academy of Medicine had provided guidance on the reallocation of scarce medical resources – including ventilators – during extreme situations. Based on focus groups and key informant interviews conducted in 2018, this study sought to understand potential barriers arising from ethical conflicts to the implementation of these guidelines for ventilator allocation in the event of resource scarcity. Participants anticipated challenges reconciling this protocol with their roles and identities as health care providers, as well as concerns about emotional consequences, and fear of legal repercussions. These concerns raise questions about the performance of such a protocol in disaster scenarios and highlight the need for disaster preparedness drills and training.

What constitutes effective team communication after an error?

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Hart WM, Doerr P, Qian Y, et al. AMA J Ethics. 2020;22:E298-E304.

Communication has become a foci of improvement efforts across the spectrum of patient safety. This article discusses a surgical complication incident that illustrates the importance of transparency, disclosure and collaboration as elements of a successful approach to communication that can successfully manage the impact of an adverse incident.

Zero harm in health care.

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Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.

Health systems are encouraged to strive for zero preventable harm, but achieving this goal requires a comprehensive, systems-focused effort. This paper discusses the rationale for using ‘zero harm’ as a patient safety goal, and the importance of broadening the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring beyond the hospital and across the care continuum. Four key elements required for successful systems change resulting in safety improvements are discussed: (1) change management, (2) culture of safety, (3) a learning system, and (4) patient engagement and codesign of healthcare.

Error disclosure and apology in radiology: the case for further dialogue.

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Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.

This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.

Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population.

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Byju AS, Mayo K. J Med Ethics. 2019;45:821-823.

Managing errors that affect patients who lack decision-making capacity and a designated decision-maker is a new area of concern. This commentary discusses moral, ethical, legal, and clinical reasons for health care to examine how to respond when such a situation occurs. The authors hope to motivate development of needed protocols and best practices to ensure that this vulnerable patient population is respectfully and completely informed after medical errors.

Patient preferences in cases of Inter-system Medical Error Discovery (IMED).

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Antunez AG, Saari A, Miller J, et al. Ann Surg. 2021;273:516-522.

Clinicians sometimes need to address errors committed by other providers, who may or may not be part of their own organization. This study used simulated cases to explore patient preferences for error disclosure when the disclosing provider was not involved in the error. Patients strongly preferred that these errors be treated similarly to other errors, asking for full disclosure whenever possible. A review article and a WebM&M commentary discuss frameworks for providers to use when disclosing errors committed by another clinician.

When there's no one to whom an error can be disclosed, how should an error be handled?

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Chiu RG. AMA J Ethics. 2019;21:E553-558.

Although disclosure of medical error to patients is difficult, it is an ethical responsibility. This article discusses situations involving patients who are incapacitated and unrepresented but have no surrogate present to assist in communication and care coordination. Despite this challenge, the author argues that the clinician and organization still have the responsibility to document what happened, communicate what is known, and rectify the mistake.

Reducing Diagnostic Error: Measurement Considerations.

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National Quality Forum

This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.

Apology and unintended harm in global health.

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Addiss DG, Amon JJ. Health Hum Rights. 2019;21:19-32.

Although disclosure and apology for mistakes in medical care are recommended, less is known about use of such approaches for overarching system failures. This commentary explores the use of apology in global health programs. The authors use case studies to highlight ethical, legal, and human rights principles that can be challenged when intervention design and implementation result in unintentional harm.

The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.

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Washington, DC: America's Health Insurance Plans; 2019.

Guidelines provide practitioners with evidence-based solutions. This report outlines use of a measure to assess adherence to six of the recommendations in the Centers for Disease Control and Prevention guideline for opioid prescribing in primary care.

Lessons learned from a death outside a hospital's doorstep.

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Palmer J. Patient Saf Qual Healthc. May/June 2019.

Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

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