Open research questions in Patient Safety and Medication Errors
183 unresolved questions extracted from the limitations and future-work sections of 1,102 Patient Safety and Medication Errors papers in our library. Each links back to the study that raised it.
What the literature leaves open
student observer bias, - recall bias, - cognitive overload, - limited experience of the students regarding clinical knowledge, - research communication, - hesitations to observe clinical teams
Exploring the use of observational tools for advancing patient safety learning among preregistration healthcare students: a scoping review using the 3P model of teaching and learning · 2026 · DOIThe lack of understanding of the most effective ways to teach patient safety to pre-registration students. The wide variations in teaching approaches. The need for a framework to understand the pre-delivery teaching set-up, the learning delivery, and the outcomes of patient safety learning.
Exploring the use of observational tools for advancing patient safety learning among preregistration healthcare students: a scoping review using the 3P model of teaching and learning · 2026 · DOIHeterogeneity of the literature on patient safety in primary health care. Limited literature on patient safety in primary health care in certain geographic contexts. Difficulty in synthesizing the existing literature due to the complexity of the topic.
Patient Safety in Primary Health Care: A Scoping Review of Characteristics, Thematic Dimensions, and Gaps in the Literature · 2026 · DOILimited literature on patient safety in primary health care, particularly in certain geographic contexts. Lack of comprehensive overview of patient safety in primary health care. Need for further research on patient safety in primary health care.
Patient Safety in Primary Health Care: A Scoping Review of Characteristics, Thematic Dimensions, and Gaps in the Literature · 2026 · DOIThe study identifies challenges in sampling NRLS reports relating to community-based mental health services. The study notes the lack of an agreed systematic way to sample NRLS reports. The study highlights the need to optimize sample relevance over sensitivity.
Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions · 2025 · DOINo agreed systematic way to sample NRLS reports relating to community-based mental health services, - The search was limited to 22 English NHS Trusts, - Incident categories such as 'failure to return from authorized leave' were excluded, - Locations such as 'prison/remand center' and 'nursing home' were excluded
Patient safety incidents within adult community-based mental health services in England: A mixed-methods examination of reported incidents, contributory factors, and proposed solutions · 2025 · DOIIndependent double-checking by two nurses is widely mandated to reduce this risk; however, evidence is lacking, compliance is inconsistent, and the procedure is time-consuming.
Targeting what matters: A quasi-experimental controlled before-and-after study on targeted double checks in parenteral medication administration · 2026 · DOIMedication safety organisations increasingly recommend targeted double-checking of high-risk medications, yet the impact of such a strategy in clinical practice remains unclear.
Targeting what matters: A quasi-experimental controlled before-and-after study on targeted double checks in parenteral medication administration · 2026 · DOIEvidence that such recommendations translate into meaningful improvement is weak and the reasons for this are poorly understood.
From Safety Science to Operational Reality: Competing Institutional Logics in the Translation of National Patient Safety Recommendations · 2026 · DOIWhile previous research has explored the relationship between PSCs and nurses’ resilience, no studies have specifically examined the association between PSCs and nurses’ turnover intention.
Impact of patient safety culture on resilience and turnover intention: a multi-site study · 2026 · DOIFactors such as densely packed curricula, gaps in the evidence-base, under-prepared faculty, and low levels of organizational support have influenced implementation.
Patient safety education in undergraduate medical education through a global lens: a scoping review · 2025 · DOIDespite research on whistleblowing in medical and nursing fields, there is limited evidence on this topic within dental education.
Breaking the silence: confidence and barriers in raising concerns among undergraduate dental students– “a national study” · 2025 · DOICONCLUSIONS: Notwithstanding the limitations of the current study, the results show that participants were marginally confident in raising concerns related to patient safety and several barriers to raising concerns were also identified.
Breaking the silence: confidence and barriers in raising concerns among undergraduate dental students– “a national study” · 2025 · DOIBACKGROUND: Each year, the Food and Drug Administration receives over 2 million adverse event and medication error reports, which are likely underreported.
Enhancing medication error reporting through interprofessional education: analysis of Medwatch reporting accuracy and completion rates between teams and individuals · 2025 · DOIAlthough several pioneering initiatives exist, a standardized, evidence-based certification framework to guide institutions in designing, implementing, and sustaining these interventions was lacking in Europe.
Standardizing second victim support: development of the RESCUE certification framework for health care institutions · 2025 · DOICONCLUSIONS: There is insufficient evidence if and how design characteristics affect learning outcomes in escape rooms aimed at training CRM/teamwork in acute care professionals.
Escape room design in training crew resource management in acute care: a scoping review · 2024 · DOIHowever, little is known about escape room design characteristics and their effect on learning outcomes.
Escape room design in training crew resource management in acute care: a scoping review · 2024 · DOIWhile the SVP has been explored in various healthcare settings, there are limited data on its prevalence and associated factors among nurses in Austria.
Furthermore, the effectiveness of these strategies in improving patient safety culture has not yet been evaluated.
However, little is known about the association of nurses' perceptions of patient safety competency with adverse nurse outcomes in Iranian hospitals.
Nurses’ perceptions of patient safety competency: A cross-sectional study of relationships with occurrence and reporting of adverse events · 2024 · DOIThrough comprehensive assessments and surveys, will be determined that a considerable portion of patients may have limited knowledge about their rights in the healthcare setting.
Evaluate the awareness regarding the patient’s rights and responsibilities among the patient visiting hospitals · 2024 · DOIThe Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described.
The study identifies a gap in the literature regarding the prevalence and factors associated with paracetamol dose errors in prescribing and administration in tertiary paediatric hospitals.
Paracetamol dosing errors at two tertiary paediatric hospitals: a retrospective analysis of prescribing and administration errors · 2026 · DOIOne limitation of our data is the lack of information on the prescribers, so we are unable to examine the role of pre- scriber experience or specialty in prescribing dose errors. Furthermore, we did not collect the indication for prescrib- ing. Electronic orders did include an indication field, but the eMM system did not require completion of this field for sign-off. Hence, indication was often not completed and was not suitable for analysis. Another important data limitation is that we were unable to review the patients’ morphology. Australian guidelines for paracetamol specify dosing based on ideal body weight in overweight and obese children [11, 21]. Overdoses are common when prescribers use actual weight rather than adjusting the dosing weight in these children. Current rec- ommendations suggest changing the dosing weight to corre- spond with the child’s height percentile on the World Health Organization growth chart [22], and this was the method we used when reviewing records. However, these charts have not been validated for all ethnic groups and may be of lim- ited use for some of the patient populations of these hospi- tals such as Pacific Islander Nations, Southeast Asians and Aboriginal and Torres Strait Islanders. The ability to visual- ise the patient and make a decision about dosing weight on the basis of morphology may have impacted the clinicians’ decisions when prescribing, a factor that could not be deter- mined when reviewing the patient record retrospectively. Our study included just two hospitals for prescribing errors and one for administration, so the results may not generalise to other hospitals. The two hospitals showed quite different trajectories of error rates over the three study years, implying that within-hospital factors are important. In addi- tion, our results from the tertiary care setting may not be applicable in other hospital settings. Our analysis of dose errors in paracetamol administra- tions was limited by the small number of observed errors. Direct observation of nurses is labour-intensive, and 796 observations is a considerable sample using this method. But this gave only 49 errors, which does not allow complex modelling of error patterns. Part of our prescribing data was collected in 2020, dur- ing the COVID-19 pandemic. In this period, half of one of our study wards was designated a COVID-19 ward. During the retrospective chart review for 2020, we excluded any patients who had a recorded diagnosis of COVID-19. The remaining patients were not systematically different from the cohorts from 2016 and 2017 in the observed characteristics. However, the overall health system and societal response to the pandemic may have affected our results for 2020.
Paracetamol dosing errors at two tertiary paediatric hospitals: a retrospective analysis of prescribing and administration errors · 2026 · DOIThe current healthcare system has limited ability to prevent avoidable hospital readmissions. There is a need for a systems-level framework to reduce readmissions. The proposed framework addresses this gap by organizing interventions into scalable tiers.
Avoidable Post-Acute Care Readmissions: A Tiered Systems-Level Framework for Communication, Coordination, and Clinical Capacity · 2026 · DOI
Most-cited papers in Patient Safety and Medication Errors
- A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population · New England Journal of Medicine · 2009 · 4,567 citations
- Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams · Journal of Organizational Behavior · 2006 · 1,991 citations
- Error in Medicine · JAMA · 1994 · 1,919 citations
- SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients · Ergonomics · 2013 · 1,115 citations
- Five Years After To Err Is Human · JAMA · 2005 · 886 citations
- Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change · California Management Review · 2003 · 690 citations
- Human factors systems approach to healthcare quality and patient safety · Applied Ergonomics · 2013 · 640 citations
- Problems with Contingency Theory: Testing Assumptions Hidden within the Language of Contingency "Theory" · Administrative Science Quarterly · 1981 · 633 citations
- Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors · Archives of Internal Medicine · 2010 · 617 citations
- Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error · The Journal of Applied Behavioral Science · 1996 · 607 citations
Most recent work
- Medical Student Perceptions of Psychological Safety in the Clinical Learning Environment · The Clinical Teacher · 2026
- Patient Safety Begins With Access · JAMA · 2026
- Effectiveness of supervision on patient safety during nursing students´ clinical practice: A systematic-narrative hybrid literature review · Nurse Education in Practice · 2026
- Impact of patient safety culture on resilience and turnover intention: a multi-site study · BMC Health Services Research · 2026
- Surgeon and Anesthesiologist Perceptions and Expectations of Each Other: Implications for Improving Collaboration · Journal of the American College of Surgeons · 2026
- Fe de erratas: Documentación fotográfica durante la colecistectomía laparoscópica segura. Actualización enero 2021 [Cir Cir. 2018;86(2):152-156] · Cirugía y Cirujanos · 2026
- Resilience Engineering concepts, Safety-II language, FRAM practice, and co-creating communities: how Hollnagel reshaped patient safety · Safety Science · 2026
- Evaluating staff safety in human services: An organizational injury assessment · Journal of Organizational Behavior Management · 2026
- Beyond the silence: Unveiling the governmental and systemic roots of patient safety barriers – Letter on Fekadu et al. · Intensive and Critical Care Nursing · 2026
- Methods to derive composite indicators used for quality and safety measurement and monitoring in healthcare: a scoping review · Frontiers in Health Services · 2026
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