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Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
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.
Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17:473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
LeCraw FR, Stearns SC, McCoy MJ. J Patient Saf Risk Manag. 2021;26:34-40.
Healthcare systems have implemented communication-and-resolution programs (CRPs) to respond and disclose serious errors and adverse events. This article describes methods used by nine teams of CRP advocates to encourage adoption and endorsement by hospitals and national medical societies at the national, state, and local levels.  
Blenkinsopp J, Snowden N, Mannion R, et al. J Health Org Manag. 2019;33:737-756.
Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.
Mannion R, Davies H, Powell M, et al. J Health Organ Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Jones CEL, Phipps DL, Ashcroft DM. Saf Sci. 2018;105:114-120.
Under the Safety-I framework, procedural violations in the health care setting might be viewed unfavorably. In the Safety-II framework procedural violations may be seen as necessary modifications within a complex work environment. The authors suggest that applying both frameworks provides deeper understanding of procedural violations in community pharmacies and may facilitate the development of targeted interventions for improving safety.
Bathla S, Chadwick M, Nevins EJ, et al. J Patient Saf. 2021;17:e503-e508.
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.
Giraldo P, Sato L, Castells X. J Patient Saf. 2020;16:e-225-e229.
The effect of disclosure of errors on medical malpractice risk remains unclear. This retrospective observational study found that the rates of disclosure did not increase between 2011 and 2013, and volume of malpractice claims also remained unchanged. These results demonstrate that physicians infrequently disclose or apologize for errors, despite efforts to encourage disclosure of adverse events.
Anhøj J, Hellesøe A-MB. BMJ Qual Saf. 2016;26.
Hospital boards have been urged to take responsibility for patient safety, but little is known about their ability to interpret quality and safety data. This study determined that data presented to board members almost never included error bars or control lines on charts or graphs, which limits ability to interpret the data. The authors advocate for use of control charts by hospital boards in quality and safety assessment and decision making.
Dreischulte T, Donnan P, Grant A, et al. N Engl J Med. 2016;374:1053-64.
Adverse drug events among outpatients are common and can lead to preventable complications. Conducted in primary care practices, this cluster-randomized trial found that a combination of professional education, electronic health record alerts, and financial incentives for practices to review potentially inappropriate prescribing decreased high-risk medication prescriptions. Investigators also observed a decrease in two of the three medication-related complications associated with use of high-risk medications, suggesting a clinical benefit to this intervention. The success of this study argues for similar larger-scale, multi-modal patient safety studies to detect modest but significant improvements.
Allard J, Bleakley A. Adv Health Sci Educ Theory Pract. 2016;21:803-17.
This ethnographic study examined the effects of top-down targets and protocols on health care providers' practices in an emergency department and a mental health ward in the United Kingdom. Top-down policy directives seemed to disrupt work patterns and led to unintended consequences.
Buckley C, Cooney K, Sills E, et al. Br J Nurs. 2014;23:268-72.
This commentary details a National Health Service trust's experience implementing a patient safety measurement tool that incentivized improvement in four areas: falls, pressure ulcers, venous thromboembolisms, and catheter-associated urinary tract infections.
Mathew R, Asimacopoulos E, Valentine P. Laryngoscope. 2011;121:2214-9.
This study found that operative complications were the most common source of medical negligence claims in otology. While claims were associated with a high rate of success in settlement, a significant proportion of the issues were nonsurgical and offer an opportunity for prevention strategies.
Ohrn A, Elfström J, Liedgren C, et al. Jt Comm J Qual Patient Saf. 2011;37:495-501.
Hospitals are being encouraged to engage patients in safety programs, in part because prior studies have shown that patients themselves can be a unique source of information about adverse events. In Sweden, clinicians are required to report cases of serious adverse events, and patients can obtain compensation for such events through a no-fault malpractice insurance system. However, this study found that more than 80% of cases where patients were compensated for severe injuries were not reported by practitioners, including many cases of health care–associated infections and diagnostic errors. The related editorial calls for hospitals to redouble their efforts to promote patient participation in reporting and addressing patient safety problems.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-36.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.