Who could disagree with the seemingly common-sense reasoning that: “We must learn from the things that go wrong.”? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some research...

BACKGROUND Mitigating or reducing the risk of harm associated with the delivery of healthcare is a policy priority. While the risk of harm can be reduced in some instances (i.e. preventable), what constitutes preventable harm remains unclear. A standardized and clear definition of preventable harm is the first step towards safer and more efficient healthcare delivery system. We aimed to summari...

To cite: Sokol-Hessner L, Folcarelli PH, Sands KEF. BMJ Qual Saf 2015;24:550–553. INTRODUCTION Consider these actual patient experiences: ▸ A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the f...

STUDY OBJECTIVES To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence. DESIGN Prospective, quasi-experiment. SETTING Ambulatory congregrate dining centers. PATIENTS Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or...

To cite: Shojania KG, Thomas EJ. BMJ Qual Saf 2013;22:273–277. TRENDS IN ADVERSE EVENTS OVER TIME: WHY ARE WE NOT IMPROVING? With widespread interest and investments in patient safety in the 13 years following the US Institute of Medicine report To Err is Human, the question has understandably arisen: have we decreased medical harm? One widely cited study showed no significant reductions in eit...