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Smith-Love J. J Nurs Care Qual. 2022;Epub Apr 28.
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. 
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.

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.

Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
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.

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

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.
Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35:258-265.
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.
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.
Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100:704-714.
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.

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

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.  
Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116:225-233.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.

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.   

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

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.