Can implementation of in situ simulation support rural emergency provider self-confidence and improve patient safety? A mixed-methods study.

The electronic health record: An essential tool for advancing patient safety

Patient safety is not a luxury

The Overarching Themes From the CLER National Report of Findings 2018.

ObjectiveTo evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety.Design, Setting and ParticipantsA before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands.Intervention(s)Internal auditing and feedback focussed on improving patient safety.Main Outcome Measure(s)The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety.ResultsThe AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05).ConclusionsInternal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.

Identifying and Learning from Mistakes

BackgroundOperating room (OR) nurses frequently experience work-related musculoskeletal disorders (MSDs) and psychological strain due to prolonged static postures, repetitive movements, and high-stress conditions. While short-term benefits of microbreak interventions have been demonstrated, evidence on their long-term effectiveness and impact on patient safety remains limited. This study aimed to evaluate the sustained effects of structured microbreaks on MSD outcomes, psychological wellbeing, and patient safety, and to explore organizational factors influencing intervention adherence.MethodsA nonrandomized, controlled, multicenter mixed‑methods study, six-month follow‑up (N = 178 analyzed) was conducted in five hospitals in Shanxi Province, China. Ninety-one OR nurses received a structured microbreak intervention (2–3-minute breaks every 30 minutes during procedures >60 minutes, including ergonomic exercises and mindfulness practices), while 87 served as controls (analyzed cohorts after attrition). Quantitative data (Nordic Musculoskeletal Questionnaire, Perceived Stress Scale, Maslach Burnout Inventory, patient safety metrics) were collected at baseline and six months. Qualitative data were gathered through semi-structured focus groups and interviews with intervention participants.ResultsCompared to controls, intervention nurses experienced significantly greater reductions in MSD prevalence (−20.9 vs −5.7 percentage points, p < 0.01) and pain intensity (p < 0.001), alongside marked improvements in perceived stress (−4.4 vs −0.6 points, p < 0.001) and burnout dimensions (emotional exhaustion: −6.3 vs −0.8 points, p < 0.001). Improvements in patient safety metrics were also observed, with larger reductions in medication errors (−7.4% vs −2.5%) and surgical site infections (−5.2% vs −1.6%), and increased patient satisfaction scores (+1.5 vs +0.5 points, p < 0.01). Qualitative findings highlighted leadership engagement, clear protocols, and cultural integration as key facilitators, while emergency cases and staff shortages posed barriers. Adaptive strategies, such as flexible scheduling, supported sustained implementation.ConclusionStructured microbreaks yielded sustained improvements in MSD outcomes, psychological wellbeing, and patient safety, with organizational support and adaptability proving crucial for long-term success. Integrating microbreaks into routine OR workflows may enhance nurse health, reduce errors, and improve patient care quality, offering a strategic, resource-feasible intervention for high-stress healthcare settings. Findings support embedding microbreaks into standard operating procedures and orientation, using leadership role‑modeling, brief “buddy” coverage, and lightweight prompts to optimize fidelity at scale.

This systematic review aimed to identify, critically appraise, and synthesize the best available literature on registered nurses' and medical doctors' experiences of patient safety in health information exchange (HIE) during interorganizational care transitions. The review was conducted according to the JBI methodology for systematic reviews of qualitative evidence. A total of 5 multidisciplinary databases were searched from January 2010 to September 2020 to identify qualitative or mixed methods studies. The qualitative findings were pooled using JBI SUMARI with the meta-aggregation approach. The final review included 6 original studies. The 53 distinct findings were aggregated into 9 categories, which were further merged into 3 synthesized findings: (1) HIE efficiency and accuracy support patient safety during interorganizational care transitions; (2) inaccuracies in content and structure, along with poor HIE usability, jeopardize patient safety during interorganizational care transitions; and (3) health care professionals' (HCP) actions in HIE are associated with patient safety during interorganizational care transitions. The results of this review identified several advantages of HIE, namely, improvements in patient safety based on reduced human error. Nevertheless, a lack of usability and functionality can amplify the effects of human error and increase the risk of adverse events. In addition, HCPs' individual actions in HIE were found to influence patient safety. Hence, the cognitive and sociotechnical perspectives of work related to HIE should be studied. In addition, HCPs' experiences of each stage of HIE deployment should be clarified to ensure a high standard of patient safety. Registration: PROSPERO CRD42020220631, registered on November 13, 2020.

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

Background: Prospectively tracking errors can improve patient safety but little is known about how to successfully implement error reporting in a home-based palliative care context. Aim: Explore the feasibility of implementing an error reporting system in a home-based palliative care program in Toronto, Canada, and describe the possible factors that may influence uptake. Design: A convergent mixed-methods approach was used. Participants prospectively documented errors using a novel reporting tool and completed monthly surveys. Following the reporting period, we conducted a semi-structured interview exploring participants’ experiences and perceived factors influencing reporting behaviors. Error, survey, and interview data were analyzed separately, then integrated for comparison. Setting and participants: Thirteen palliative care physicians from a single home-based palliative care organization in Toronto, Canada anonymously reported errors between October 2021 and September 2022. Of these, six participated in the exit interview. Results: Participants reported 195 errors; one-third (n = 65) involved internal staff or systems. Three themes describe the factors impacting the likelihood of reporting errors: (1) High levels of cognitive burden decreases the likelihood of error reporting; (2) Framing errors as opportunities to learn rather than reason for punishment improves likelihood of error reporting; (3) Knowing that error data will improve patient safety motivates individuals to report errors. Conclusions: Physicians are amenable to error reporting activities so long as data is used to improve patient safety. The collaborative nature of care in a home-based palliative care context may present unique challenges to translating error reporting to improved patient safety.

This pilot study aimed to determine the effect of nurse/physician interdisciplinary team training on patient falls. Specifically, we evaluated team training in a simulation center as a method for targeting and minimizing breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines. Registered nurses (RNs) were randomly assigned to participate. Residents were divided into groups and assigned based on their availability and clinical responsibility. All participants completed a demographic form, the Professional Practice Environment Assessment Scale (PPEAS), and the Mayo High Performance Teamwork Scale (MHPTS) after consenting and before participation in simulation training. The PPEAS and the MHPTS were readministered at 2 and 6 months after the simulation experience. Differences in MHPTS and PPEAS scores between the baseline and 2- and 6-month assessments were analyzed; fall rates over time were evaluated using Cochran-Armitage trend tests. After the team training exercises, teamwork as measured by the MHPTS improved significantly at both 2 and 6 months (P = 0.01; P < 0.001) compared with baseline measurement. Practice environment subscores, with the exception of positive organizational characteristics, also increased when measured 6 months after training. The primary outcome, reduction in anticipated patient falls, improved significantly (P = 0.02) over the course of the study. Results of this pilot study show that team training exercises result in improvement in both patient safety (anticipated patient falls) and team member perception of their work environment. If validated by other studies, improvement in this patient safety metric would represent an important benefit of simulation and team training.

This study aimed to investigate the potential impact of the Target Management Card on patient safety in the emergency department. A mixed method design was developed, combining a one-group pretest-posttest design with a qualitative study. Target Management Cards were formulated for 32 emergency nurse practitioners and focus group interviews were conducted after the intervention. Wilcoxon's signed rank test was used to compare pre-test and post-test scores. The interview data were subject to content analysis. After developing the Target Management Card, there were significant improvements in safety behaviors (Z = 4.709, p < 0.01) and perception of patient safety (Z = 4.257, p < 0.01) among emergency nurse practitioners. The nurses in the focus group interviews agreed that the Target Management Card could improve patient safety by warning and supervising nursing work in the emergency department, promoting a positive change in nurses' attitudes and behaviors toward patient safety. Our study found that nurses and nursing managers jointly formulating Target Management Cards in emergency departments significantly enhances patient safety.

Letter to the editor concerning 'can implementation of in situ simulation support rural emergency provider self-confidence and improve patient safety? A mixed-methods study'.

Introduction Medication errors and near misses in the community pharmacy dispensing process have the potential to adversely impact patient safety. The World Health Organisation has identified the importance of Human factors (HF) in the Patient Safety Curriculum guide (1). However, there is a lack of knowledge on how HF principles have or could be applied in the community pharmacy setting. Adopting a HF approach and using qualitative methods can provide in-depth understanding of factors that contribute to these errors, and contribute to intervention development that may improve patient safety. Aim The study aims to investigate the factors contributing to medication dispensing errors and near misses in community pharmacy, and to gather pharmacists’ views of these factors and how these could be mitigated. Methods Three Irish community pharmacies were recruited and provided details of the last ten dispensing errors or near misses which occurred. Each error was mapped to the Hierarchical Task Analysis (HTA) steps developed for this study, and mapped to the Systematic Human Error Reduction and Prediction Approach (SHERPA) framework (2). A detailed report was prepared for each pharmacy outlining the error analysis, with recommendations to prevent the errors in future. A qualitative semi-structured interview was conducted with the three pharmacists in the recruited pharmacies to discuss the report, and analysed by thematic analysis. Results A total of 30 medication errors/near misses were analysed (10 errors reached the patients and were not administered). The HTA developed outlines 185 subtasks potentially involved in dispensing a prescribed medication. On mapping to the SHERPA framework, selection-based errors were the most frequently reported error category (21/30, 70%); this included incorrect product selection from the shelf (17/30, 56.7%) and incorrect product selection at the point of computer entry (4/30, 13.3%). Of the 75 HTA steps involved across the 30 errors, the most frequent point of error was in the gathering medication steps (47/75, 62.7%), followed by the pharmacist accuracy check steps (16/75, 21.3%) and patient mix up errors (5/30, 16.7%). The pharmacist interview themes found that cognitive burden, fatigue, distraction and staffing deficiencies were reported as increasing the risk of error and near miss. Knowledge gaps and inexperience with certain medications were also reported as contributing to errors. Recommendations to prevent errors included changes to the physical environment (e.g. using product shelf alerts), improved checking processes and taking short mental breaks. Conclusion This study found that the most common errors/near misses were at the product selection stage of dispensing, with pharmacy accuracy checks sometimes, but not always, detecting these before they reached the patient. Medication errors occur due to several varying and often interacting factors; cognitive burden and lack of standardised medication checking processes. Despite the small sample size and potential for social desirability bias in the interviews, this study has demonstrated how HF techniques can be applied to the dispensing process as a means of understanding and preventing error occurrence in the community pharmacy. References (1) Vosper H, Hignett S. A UK perspective on human factors and patient safety education in pharmacy Curricula. Am J Pharm Educ. 2017;82:6184. (2) Sutherland A, Ashcroft DM, Phipps DL. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child 2019;104:588-595.

Program Directors Patient Safety and Quality Educators Network: A Learning Collaborative to Improve Resident and Fellow Physician Engagement.

Shaping Up: Unit‐to‐Unit Handoffs with a Lean Six Sigma Work Out