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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. 

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.

Institute for Healthcare Improvement. Sept 7 - Nov 15, 2022.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68:356-363.
Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.
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.
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.

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.

Diagnosis (Berl)2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.   
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.  
Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.
Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21:797-805.
Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.
Macrae C. BMJ Qual Saf. 2014;23:440-5.
This commentary examines how minor risks, when propagated and not addressed, may result in organizational disasters, as evidenced in the Francis report. The author advocates for early detection of workarounds and routine investigations into system causes of errors to reveal latent safety hazards in health care.
Matlow AG, Moody L, Laxer R, et al. Arch Dis Child. 2009.
Several studies have shown that patients clearly prefer full disclosure of medical errors and near misses. Despite this preference, physicians continue to "choose their words carefully" when discussing errors, and often fail to explicitly acknowledge errors or offer an apology. This survey of parents of children seen in inpatient and ambulatory settings confirmed prior studies in finding that parents desire full disclosure of errors and near misses affecting their children, and most parents also wanted their children informed. Interestingly, parents born in Asia had a lower threshold for disclosing errors to their children, implying that cultural factors may influence views on error disclosure. An AHRQ WebM&M commentary discusses an error that was disclosed to a parent and the consequences that followed.