Background The assessment of medical malpractice has traditionally focused on legal responsibility and individual accountability. However, legal classifications may provide only limited insight into mechanisms leading to patient harm and may therefore not fully support the development of preventive patient safety strategies. This challenge may be particularly relevant in neurosurgery, where unexpected intraoperative events frequently require adaptive decision-making beyond routine algorithms. Objective This perspective proposes a patient safety-oriented framework for the analysis of harmful neurosurgical events, using the Swiss healthcare system as an illustrative example. Conceptual framework The proposed approach consists of three complementary elements: (1) a taxonomy distinguishing errors, negligence, safety incidents, and adverse events; (2) a legally supported, independent reporting and analysis platform designed to facilitate transparent system learning and non-punitive evaluation of treatment-related harm; and (3) greater emphasis on the development of adaptive surgical expertise and organisational structures capable of managing non-routine intraoperative crises. Conclusions Complementing traditional legal assessments of malpractice with systematic analyses of mechanisms of harm, safety barriers, and adaptive surgical performance may provide a comprehensive approach to improving neurosurgical safety culture. A framework integrating transparent reporting, multidisciplinary learning, and preparation for unexpected intraoperative challenges may contribute to the prevention of future patient harm.
Background Effective communication is essential in hospital-based care, with hospitalists playing a pivotal role in ensuring smooth in-patient management and care transitions. Despite its recognized importance, gaps remain in understanding how hospitalists communicate with clinicians, patients, and other stakeholders. This review consolidates existing evidence on hospitalist communication practices, handoff protocols, key challenges, and opportunities for improvement. Methods A systematic literature review was conducted following PRISMA guidelines. Searches were performed in PubMed, EMBASE, and SCOPUS for studies published from 1 January 2014 to 23 December 2024, with additional manual entries from a curated set. After removing duplicates and applying inclusion/exclusion criteria, 66 articles were identified. A two-stage screening process (title/abstract and full-text review) resulted in 38 studies selected for data extraction. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) (1); no studies were excluded based on quality. Results Three primary communication domains emerged: clinician-to-clinician interactions, communication with patients, and engagement with other stakeholders, including families and interpreters. Standardized handoff tools were associated with improved communication and outcomes. Challenges in hospitalist communication include incomplete information exchange, role ambiguity, and limited trust. Several studies emphasized the potential of digital tools, telehealth, and targeted training to address these issues. Conclusion While progress has been made through standardized communication protocols, critical challenges remain in this domain. The paper recommends targeted interventions to address persistent barriers that hinder hospitalist communication, improve patient safety, and ensure smoother transitions and continuity of care within hospital systems.
Background Despite two decades of promoting systems-based approaches, healthcare safety investigations often fail to produce system-level changes. This study analyzed the quality of recommendations from serious incident investigations conducted by multidisciplinary teams in Finland. Methods Serious incident investigation reports (n = 169) from 2018 to 2023 were collected from 11 well-being services counties, with a total of 525 recommendations being extracted and classified as weak, intermediate, or strong according to the US Department of Veterans Affairs’ National Center for Patient Safety criteria. Each recommendation was assigned only to one strength category. Results More than half of all recommendations were weak (56%) and focused mainly on staff training (43%) and new procedures or policies (39%). Intermediate recommendations comprised 37%, primarily targeting documentation and communication (63%), while only 7% were strong. Approximately one in four investigations (24%) included at least one strong recommendation. Mentions of recommendations being implemented were rare (20%), and only 7% included follow-up notes. None of the reports specified the analytical method used. Conclusions Finnish healthcare's serious incident investigations produce predominantly weak, behavior-focused recommendations that are seldom followed-up or implemented. The absence of standardized reporting formats and limited documentation of follow-up hinder the evaluation of impact. To strengthen patient safety, investigations should yield fewer, but stronger, system-oriented recommendations developed using structured analytical methods and evaluated through consistent national guidance and monitoring mechanisms.
Communication and resolution programs (“CRPs”), a principled process that guides health system response following harm events, are becoming standard of care. Despite this, there is a paradox at the heart of CRP implementation. Although physicians are critical to CRP success, they are too often disengaged in the CRP process. This article explores the barriers to physician CRP engagement and offers tangible strategies to overcome those barriers.
Since the Institute of Medicine's 1999 To Err is Human report, there has been a flurry of safety activity, including, but not limited to, improved voluntary safety reporting culture, standardization of safety practices, introduction of root cause analyses, safety event debriefs, and fortified institutional infrastructure to support safety work. These practices are used to examine failures and identify areas for improvement. Despite the significant prioritization of safety work, there is evidence to suggest that improvements have been minimal. The purpose of this commentary is to highlight three measurement deficiencies that have been largely overlooked but contribute significantly to the measurement challenge. In doing so, we aim to deepen our understanding of the many challenges we face as a safety community, enabling us to make more informed decisions about measurement going forward.
The process involved each step within the patient's journey from the time the order was placed for an imaging procedure, the completion of that exam, and departure of the patient back to the originating unit. The FMEA committee was able to successfully identify five out of the 28 process steps with the highest opportunity for improvement. From there, each step was connected to an action plan that was hardwired into the day-to-day workflow and memorialized with updated policies as well as associated workflow algorithms. We achieved our goal of zero SSE5 for all of 2020 and through July 2021.
Background Incident reporting systems are increasingly recognized not only as surveillance mechanisms but also as essential tools for organizational learning and healthcare risk management. While ultrasound is widely regarded as a safe and noninvasive diagnostic modality, the expanding scope of its use has introduced new patient safety risks that remain insufficiently characterized.Methods We conducted a retrospective analysis of 160 ultrasound-related incident reports submitted to the national database of the Japan Council for Quality Health Care between 2014 and 2023. Incident characteristics were analyzed descriptively, and contributing factors were classified using the SHELL model framework to identify system-level vulnerabilities relevant to healthcare risk management.Results Most incidents occurred during weekday daytime hours (84% on weekdays; 78% between 08:00-17:59). Although the majority required no or minor intervention, 16% involved significant medical treatment. SHELL model analysis revealed that Liveware (human factors) accounted for 68.1% of contributing factors, followed by Software (21.3%) and Hardware (10.6%). No statistically significant association was observed between SHELL categories and severity of harm.Conclusions Ultrasound-related incidents are primarily driven by human and system interface factors rather than device failure alone. These findings highlight the importance of risk management strategies that emphasize human factors engineering, standardized protocols, and nonpunitive learning-oriented incident reporting systems. National incident databases can serve as valuable resources for identifying latent risks and informing proactive patient safety interventions.
Background Medication errors with liquid pediatric formulations are a pressing patient safety concern. This study evaluated the effectiveness of a pictogram-based instruction package in reducing home medication errors made by caregivers compared with a text-based instruction label. Methods This randomized controlled trial (RCT) recruited 134 caregivers of children prescribed reconstitutable oral antibiotics using convenience sampling. Participants were randomly assigned to receive either pictogram-based instructions (intervention group) or standard text-only labels with verbal explanation (control group). Drug reconstitution errors were directly observed, while potential administration errors were self-reported. Caregiver label preferences were also evaluated. Outcomes between the groups were compared using Chi-square tests, and risk ratios (RR) were calculated to determine the intervention's effect size. Results The pictogram-based intervention led to a significant reduction in medication errors. The intervention group (n = 69) had substantially fewer reconstitution errors compared to the control group (n = 65) (21.7% vs. 84.6%; risk ratios (RR) = 0.26, 95% confidence interval (CI): 0.16-0.41, p < 0.001) and fewer self-reported potential administration errors (8.7% vs. 84.6%; RR = 0.10, 95% CI: 0.05-0.22, p < 0.001). Notably, errors related to incorrect water volume and misinterpreted dosing intervals and duration were significantly reduced. Over 92% of caregivers in both groups expressed a strong preference for instructions combining pictograms with text, citing improved clarity and ease of understanding. Conclusion In this RCT, a pictogram-based instruction package was a highly effective and simple risk management tool that significantly reduced caregiver medication errors. Its implementation is a promising strategy to enhance medication safety and adherence in diverse pediatric populations.
Background Patient safety remains a critical challenge in healthcare services. The study objective was to compare advanced practice nurses, physician assistants, and attending physicians' responses to overall patient safety ratings and error reporting.Methods A dataset from the Agency for Healthcare Research and Quality provided responses related to patient safety and error reporting submitted by 3659 advanced practice nurses, 1044 physician assistants, and 5140 attending physicians. The Hospital Survey of Patient Safety Cultural version 2.0 was the instrument used in this study. A secondary data analysis was conducted with the dataset.Results Respondents identified the hospital settings as teaching (70.6%) and nonteaching (29%); ownership included public government (18%), public nongovernment nonprofit (73%), and private nongovernment for-profit (9%). Respondents identified their work areas as multiple units, medical/surgical units, patient care units, surgical services, or clinical services (76%). Findings showed each of the three hospital positions rated patient safety significantly differently. Advanced practice nurses rated patient safety lower (& micro; = 3.4) than physician assistants (& micro; = 3.6) and attending physicians (& micro; = 3.8). Linear relationships were also found to be significantly different, indicating that the level of position correlates with changes in error reporting and overall patient safety ratings.Conclusions The key to meeting the goal of "zero" harm and National Steering Committee's goal for healthcare systems to foster and sustain a robust safety culture is first recognizing that errors do occur.
Background Patient harm from healthcare is prevalent, serious, and can be long lasting. How healthcare organizations respond has implications for patients, families, healthcare professionals, and organizations. We sought to synthesize the evidence on the effectiveness of communication and resolution programs (CRPs).Methods Harm response programs that incorporated communication with patients and families, event review, quality improvement, and in a qualifying subset of events, an apology and an offer of compensation were included. We searched PubMed and the Cochrane Library for systematic reviews and primary studies published from 1 January 2010 to November 2025, supplemented by a review of gray literature.Results We retrieved 2801 citations, of which nine primary studies and no systematic reviews were identified as eligible. The studies focused on medical malpractice experience and financial outcomes. The most robust CRPs reduced the rate of claims, and defense legal fees and expenses (strength of evidence: low). Time to resolution, rate of lawsuits, overall costs to healthcare organizations, and settlement amounts decreased or had no significant change. Evidence was lacking or limited for CRPs' effects on: other aspects of patient, family, or clinician outcomes or experience; patient safety; quality of care; communication and relationships between patients, families, and organizations; and interprofessional communication.Conclusions CRP implementation is supported by evidence of positive or neutral effects on organizational liability and cost outcomes, but more research is needed to determine the effects on patient, family, and clinician-oriented outcomes.
Background Drug-related problems (DRPs) are a frequent and preventable source of morbidity in emergency departments (EDs). Machine learning (ML) has the potential to improve early DRP detection and risk stratification.Objective We aimed to develop and validate two ML-based models for predicting DRPs in ED patients, and to compare their performance with a conventional logistic regression model, using routinely collected data during standard pharmacy working hours.Methods We performed a retrospective observational study in the ED of a tertiary university hospital (March-June 2025). Adult patients (>= 18 years) with at least one prescribed medication, attended from Monday to Friday 08:00-15:00, were included. Predictors comprised age, sex, ED length of stay, frailty score, triage level, admission diagnosis, planned hospital admission, high-alert medications, and prior isolation of multidrug-resistant bacteria. A random forest (RF) model, a K-means clustering approach, and a multivariate logistic regression model were developed. Model performance was assessed by area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy in separate training (80%) and validation (20%) cohorts.Results Of 5064 patients (mean age = 72.1 +/- 19.6 years; 53.6% female), 823 (16.2%) presented >= 1 DRP. Medication reconciliation errors were most common (45.5%). In the training cohort, AUCs were 0.685 for logistic regression, 0.720 for RF, and 0.551 for K-means clustering. The RF model achieved sensitivity 0.727 and specificity 0.529, improving logistic regression results (sensitivity 0.864; specificity 0.378).Conclusions RF decision model modestly outperformed conventional logistic regression for DRP risk stratification in the ED. Integration of such ML tools may enable early identification of high-risk patients.
Background Safety recommendations are one of the most widely used tools for translating analysis of safety issues into improvement actions, but can sometimes complicate and confuse rather than support systemic safety improvement efforts.Methods This paper explores the range of problems that can limit the effectiveness and impact of safety recommendations, and uses these problems as a basis for articulating a set of guiding principles which may support more systematic and robust approaches to making and monitoring safety recommendations.Results One of the most notable problems with safety recommendations in healthcare is the enormous quantity and abundance of recommendations that are produced, which can overwhelm those who are expected to act on them. Other problems include a lack of rigour in identifying and analysing the safety risks that recommendations aim to address, variability in specifying the risks to be addressed and the improvements to be achieved, and limited integration or connection between recommendations. Recommendations can also be inappropriately used as a management tool, can become confused with orders or requirements for compliance and can have little supporting infrastructure for ensuring system improvements actually result.Conclusions This paper explores these problems and argues that addressing these problems requires systematic and robust processes for defining the risks that need to be targeted by recommendations, as well as more sophisticated governance systems for supporting coordinated improvement activities. A set of eight principles is proposed, which can support a more systematic, integrated and robust approach to developing and using safety recommendations.
Background Safety event communication is imperative to reduce repeat events within a hospital. We realized that when an event occurred, follow-up and action items were implemented at the local level but there was not a way to quickly alert other areas within the hospital who may be at risk for a similar event.Methods A standardized method was developed to communicate and prevent similar events. An algorithm was developed to help define what events are communicated and how another area can assess the risk within their local area and intervene as needed. When all areas were notified via a communication alert that a safety event happened in a local area, the patient safety leaders systematically assessed the risk of a similar event in their area. The leaders then replied to the communication alert system indicating that they had performed the risk assessment.Results In the first 19 months, 65 safety event alerts were sent. Members from the team responded a total of 959 times with their next steps after learning about a safety event. Of the 959 comments, 48 of the comments were conversational, 403 of the comments stated there was not risk of a similar event in their area, and 508 indicated that there was risk of a similar event happening in their local area and that action was taken to mitigate that risk. This resulted in 508 times when the safety leaders in other areas throughout the hospital developed local plans to prevent a repeat event.Conclusion Reducing safety events in the hospital setting is a complex process. Communication of known events could potentially reduce de ja vu events. The risk assessment process is one way to spread communication and response to safety events as they occur.
Background In 2024, the study institution noted a trend of safety events involving intravenous immunoglobulin (IVIG). An audit revealed the majority of the events were identified during administration. The largest contributor to administration events was improper selection and use of weight during infusion pump programming. The objective of this study is to evaluate the impact of pharmacist-led interventions on dose-weight infusion pump programming during IVIG administration.Methods This single-center, quasi-experimental study included two groups of patients who received IVIG during an inpatient admission; a preintervention group that included patients between October 15th, 2024 and January 13th, 2025, and a postintervention group that included patients between March 25th, 2025 and June 3rd, 2025. Interventions targeted the electronic health record (EHR), infusion pump drug library, and nursing procedures. The primary outcome was the proportion of IVIG administrations with appropriate dose-weight infusion pump programming. Secondary outcomes included adverse drug reaction occurrence, reaction severity, epinephrine administration, and infusion completion.Results A total of 311 IVIG administrations were included for evaluation of the primary and secondary endpoints. In the postintervention group, a greater proportion of administrations achieved the primary endpoint (76.3% vs 65.3%; chi 2 = 4.166; P = 0.041). Adverse drug reaction occurrences (1.7% vs 4.7%) and epinephrine administrations (0% vs 1.0%) were decreased in the postintervention group. The rate of infusion completion was increased in the postintervention group (100% vs 98.4%).Conclusions Implementation of interventions to simplify and support appropriate IVIG administration improved the proportion of administrations utilizing appropriate dose-weight infusion pump programming.
Background Surgical-and-Perioperative Risk Prediction Calculators (SPRPCs) help predict patients' safety outcomes for proposed surgical procedures. These evidence-based assessments can inform shared decision-making between patients and providers - improving patient safety, satisfaction and care. However, evidence persistently indicates low use of SPRPCs in surgical care. We reviewed qualitative literature to explore surgeons' and anaesthetists' attitudes and perceptions of features of SPRPCs, facilitators, barriers and complexity influencing their adoption.Method A systematic literature search was performed across three bibliographic databases. A two-stage screening process was performed using pre-determined inclusion and exclusion criteria. The Joanna Biggs Institute (JBI) checklist was used to critically assess quality. Qualitative data from included studies were analysed using thematic synthesis.Results Four qualitative and two mixed-methods paper were included, reporting data from 72 clinicians in total. Three studies focused on orthopaedic surgery SPRPCs, two on the Surgical Perioperative Assessment System tool and one on post-anaesthetic care unit hypotension prediction. Six facilitator, and four barrier, themes were identified. SPRPCs were seen as valuable in lowering patients' risk of harm and supporting: informed consent discussions, declining surgery, and staff communication. These benefits were contingent on SPRPCs being transparent, accurate and integrated with care pathways. Conversely, some argued SPRPCs do not change clinical decisions, pose a threat to autonomy and patient-centred care and open the clinician to legal liability.Conclusions SPRPCs are underutilised when developed without consideration of clinicians' needs and workflow. Findings highlight the importance of clinicians' involvement in SPRPC design. Further research would support improvements in their clinical adoption.
Background Effective teamwork and communication are crucial in surgical settings to ensure patient safety and deliver high-quality care. Operating Room Nurses (ORNs) play a critical role in managing complex technological environments and coordinating with multi-professional teams. Despite the recognised importance of teamwork, limited research exists on how ORNs perceive and experience teamwork and learning in paediatric operating rooms.Aim This study aimed to explore the perceptions of operating room nurses regarding teamwork and learning processes within paediatric perioperative care settings.Method A phenomenographic design was employed, involving semi-structured interviews with ten ORNs who had completed an advanced course in perioperative paediatric care. Participants were selected through purposive sampling from six hospitals across Sweden. Data were analysed using a seven-step phenomenographic approach to identify variations in understanding.Results Two distinct approaches to teamwork and learning emerged: a team-oriented approach, emphasising shared experiential learning and communication within the team, and a personoriented approach, focusing on individualised patient care and preparation through diverse informational resources. Subcategories included 'Communication 'and 'Reading about the patient, 'highlighting the importance of interprofessional collaboration and holistic patient understanding.Conclusion The findings highlight the dual perspectives of teamwork and learning among ORNs, with implications for improving patient outcomes and safety. Integrating both team-oriented and person-oriented approaches in training programs may promote adaptive teamwork and interprofessional learning. Further research is needed to explore team maturity and its impact on clinical practice.
Introduction Tilting an operating room table, though frequently needed to optimize surgical exposure, is associated with an increased risk of falls. While safety straps mitigate the risk of a fall should the patient start to slide, few tools can predict settings in which falls are likely to occur. The purpose of this study was to develop and validate a predictive biomechanical model for degree of table tilt associated with patient movement and risk of falling. Methods A model incorporating patient's body mass index (BMI) was designed to predict the maximum angle a table could be tilted before patient movement occurred. The model was developed using SolidWorks computer simulation and validated with 19 unrestrained, non-anesthetized volunteers. Movement on the table was self-reported and observed by the researchers as the table was tilted laterally and in reverse Trendelenburg (RT). Volunteers were categorized by BMI ("normal": 18.5-24.9, "overweight": 25-29.9, "obese": >29.9). Fit of the model was assessed using mean square error, and predicted angles were compared to experimental outcomes using the Student's t-test (P < 0.05). Results In both the overweight and obese BMI groups, no significant difference was noted between predicted and experimental angles. In volunteers with a normal BMI, the model underestimated the lateral angle, but accurately predicted RT. Overall, lateral angles were smaller than RT. Conclusions This model can predict patient sliding in the operating room, though it underestimates the maximum angle of slipping in the lateral direction among those with a normal BMI. Larger studies are needed for validation and feasibility of implementation.
