Resources

Medication errors remain a stubbornly challenging issue in the provision of safe care. Although we often associate inpatient settings with medication issues, this comprehensive review studied the triumvirate of prescribing, dispensing and administration to determine common causal factors of mistakes and inaccuracies, leading to incidents in ambulatory and outpatient settings.

Correct identification of patients has been recognised as a critical safety issue for many years. A recent report from the UK’s Health Services Safety Investigation Body (HSSIB), compiles evidence from various investigations and sources to explore the factors contributing to patient misidentification in healthcare. The report defines 'positive patient identification' as the accurate identification of a patient to ensure they receive the correct care. Whereas, 'patient misidentification' occurs when a patient is wrongly identified as someone else, leading to potential harm from incorrect or missed treatment.

This Failure Modes and Effects Analysis (FMEA) Tool, provided by the Institute for Healthcare Improvement (IHI), is a comprehensive resource designed to help human services systematically identify and mitigate potential risks in clinical processes.

We spend a lot of time on root cause analysis (RCA) – and have done it for 20 years or so. But key clinical risks remain stubbornly consistent.

Outpatient safety receives a different level of discussion and focus than inpatient safety. We may not consider that outpatients can experience harm in the same way that inpatients can, which could reduce the focus on collecting accurate outpatient incident data. But even outpatient care can cause life-threatening harm, as this study shows.

Striking a balance between patient safety and professional autonomy is a complex issue that requires a multifaceted approach. Multiple challenges stand in the way of a balanced approach, such as...

Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavourable outcomes can limit innovation and adaptability, not to mention undermine worker morale and engagement.

Numerous studies about the use of trigger tools to identify adverse events (AEs) have been performed in hospitals. However, the research conducted on the use of trigger tools to identify AEs in primary care is limited. 

This study developed a set of triggers for identifying adverse events in Primary Care, from health record reviews with high positive predictive value (PPV), making it easier to collect reliable information on care-related incidents in this sector. It also presents interesting data on adverse event prevalence in Primary Care.

In this webinar, Tracey Hynes, Director at Maternity Care Consulting discussed how to recognise failures in your systems.

Ensuring organisations learn from patient safety incidents is a key aim for human service organisations. The role that human factors and systems thinking can have in enabling organisations to learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems.