Letter From the Editor
With this issue, we celebrate our three-year anniversary of Patient Safety! When we began this journey, we sought to highlight the intersection of patient safety science and real human experience. I hope you believe we’ve done just that! We are proud to bring you manuscripts that identify issues placing patients in harm’s way along with the nuts-and-bolts strategies to minimize those risks, as well as stories of the people involved in the day-to-day challenges of providing and receiving safe healthcare.
This issue captures that intersection so well. In recognition of World Cancer Research Day on September 24, Patient Safety managing editor Caitlyn Allen sat down with Dr. Joe Jacobson from the Dana-Farber Cancer Institute, a world-renowned oncology center in Boston, to talk about the unique challenges that both patients and providers face while navigating not only complex diagnoses, but also complex systems.
This issue also highlights the significant but underappreciated risks of a common medical device found in every healthcare facility: wheelchairs. The first U.S. patent for a folding wheelchair was filed in 1937 by Harry C. Jennings, Sr., and Herbert A. Everest—not exactly new technology. Molly Quesenberry, a patient safety liaison at the Patient Safety Authority (PSA), discusses the serious injuries from wheelchairs uncovered during a weekly review of events.
Lucy S. Bocknek et al. share their findings after reviewing events related to duplicate medication orders. While health information technology (health IT) promised to eliminate these types of errors, their analysis shows these events still happen. They offer strategies to protect patients and suggest that healthcare facilities take a closer look at how health IT may contribute to these events instead of mitigate them.
In a further tribute to cancer research, Cassandra Vonnes and Cindy Tofthagen share a quality improvement initiative aimed to better manage delirium in cancer patients—a serious problem during acute hospitalizations and end-of-life care. Their manuscript underlines the importance of screening and early intervention.
To celebrate World Patient Safety Day—whose theme this year is “Medication Without Harm”—this issue includes an overview of patient safety in Canada by Ioana Popescu and an interview with Institute for Safe Medication Practices (ISMP) Fellow and PSA director of Outreach and Education, Michelle Bell, and medication safety officer at Children’s Hospital of Philadelphia, Sharon Camperchioli.
Also included in this issue, Kristin Neiswender et al. describe how they used the results of a culture of safety survey to create real change in their healthcare facility, and Mayher Profita provides a true-life account of burnout and its effects on not only her life, but also the lives of patients.
This journal was designed for our authors to freely share the important work they do to improve patient safety, and for our readers to freely receive the information, strategies, and lessons learned to make the care they provide and receive safer. Thank you to our authors, reviewers, staff, editorial board, and readers for your continued contributions.
Stay safe and stay well!