Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.
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.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
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.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Dennison S, Freeman M, Giannotti N, et al. Nurse Educ. 2022;47:202-207.
Reporting medication errors and near misses should be taught to prelicensure nursing students but is not always included in nursing programs. This quality improvement project focused on the near-miss medication error reporting by student nurses. The authors found that dosing errors were 81% of the incidents, but there were multiple contributing factors including communication, competency and education, environmental and human limitations, and policies and procedures. The findings can be helpful to other nursing programs to refocus education on medication errors to areas were students have problems.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Thomas AD, Pandit C, Krevat SA. J Patient Saf. 2021;17:e1605-e1608.
Building on prior research, this study identified racial differences in voluntarily reported near-miss events. Compared to white patients, black patients had fewer reported events but were more likely to experience near-miss events related to laboratory/specimen handling, blood bank, and safety/security.
Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99:693-707F.
Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.
Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.
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.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
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.
Weprin SA, Meyer D, Li R, et al. Patient Saf Surg. 2021;15:14.
A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.
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.
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.
Campbell AA, Harlan T, Campbell M, et al. J Nurs Scholarsh. 2021;53:333-342.
Using electronic health records, call light systems, and bar-code medication administration systems, this study examined the impact of six specific workload variables on nurses’ medication administration errors. At least one of the six variables was significantly associated with the occurrence or nonoccurrence of a near miss medication error in the majority of nurses. Because the specific variable(s) differed for each individual nurse, interventions addressing medication administration errors should be tailored to individual nurse risk factors.
Street RL, Petrocelli JV, Amroze A, et al. J Patient Exp. 2020;7:1247-1254.
Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.
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