All Content

Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).

Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

Patient satisfaction surveys, unexpected event reports and patient complaints can each be used to improve patient safety. This radiotherapy service combined the three sources to make improvements in safety and quality. Results highlighted areas of strength (e.g., physical healing, kindness) and areas to improve (e.g., scheduling, comfort). Involving the patient in this way could lead to improvements in quality and safety.

Effective incident reporting systems play an essential role in identifying and mitigating patient safety threats. This article discusses the need for a standardized approach to incident report analysis and how qualitative content analysis can support incident analysis and help identify risk mitigation strategies, performance improvement initiatives, and educational opportunities for healthcare workers. 

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. 

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.

There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.

Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.

Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 

The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.

In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.

This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.

This study merged inpatient discharge data with annual survey data from the American Hospital Association and found that private patient rooms were significantly associated with fewer hospital-acquired MRSA infections; however the effect of private rooms is disproportionate across hospitals. Hospitals with fewer private rooms stand to see the greatest decrease in MRSA infections from adding additional private rooms. These findings can assist hospital administrators making decisions about facility design and renovation.

Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.