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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 3
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications
- Medication Safety
- Psychological and Social Complications 1
- Surgical Complications 1
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National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Journal Article > Study
Lipczak H, Knudsen JL, Nissen A. BMJ Qual Saf. 2011;20:1052-1056.
A comprehensive view of patient safety hazards requires identifying safety issues through multiple data sources. This Danish study analyzed safety problems in oncology care through voluntary error reports, retrospective chart review using the Global Trigger Tool, and patient reports. While each data source revealed unique hazards, common problems in this patient population included treatment-related harm (from chemotherapy and other procedures), health care–associated infections, and problems related to communication between providers. An AHRQ WebM&M commentary discusses a preventable complication in a patient receiving outpatient chemotherapy.
Journal Article > Study
Preventable and mitigable adverse events in cancer care: measuring risk and harm across the continuum.
Lipitz-Snyderman A, Pfister D, Classen D, et al. Cancer. 2017;123:4728-4736.
Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.