Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.

Pay-for-performance (P4P) policies and programs (such as the Hospital-Acquired Condition [HAC] Reduction Program) intend to incentivize high-quality care and reduce medical errors. This systematic review including 53 articles explored the impact of P4P on the incidence of adverse events in acute care settings. The researchers found that half of the included studies did not identify improvements in adverse event rates after P4P, and that studies reporting improvements were of poor methodological quality.

Front-line workers (e.g., nurses and physicians) and leaders frequently perceive the safety culture in their organization differently. This study uses data from AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) V.1.0 from 2008 - 2017 to compare leadership and front-line workers' perceptions of patient safety culture. With responses from 1,810 hospitals and more than 800,000 individuals identified as leaders or front-line workers, results show that leadership has a consistently more positive perception of patient safety culture, particularly on items related to managers.

The I-PASS tool has been implemented in a variety of healthcare settings to improve communication during patient handoffs. This article describes the implementation of an electronic health record (EHR)-based I-PASS tool used to standardize handoff documentation among fellows, residents, advanced practice providers (APPs) and physician assistants (PAs) at one Comprehensive Cancer Center. After I-PASS training, tool adherence improved from 42% to 71% and perceived handoff scores improved on safety culture surveys.

Inpatient falls are a persistent patient safety challenge. This study evaluated the impact of video monitoring (VM) plus in-person sitters on falls among high-risk patients at one academic hospital system. The researchers found that patients admitted after VM implementation had a lower risk of falls.

The National Healthcare Safety Network (NHSN) tracks healthcare-associated infections as well as improvement efforts. This article describes NHSN use of digital quality measures (dQMs) and other online resources to reduce the reporting burden and improve the quality of surveillance data.

Healthcare facilities are routinely subjected to accreditation processes to ensure the delivery of evidence-based care. This scoping review examined whether limited advanced warning of an impending accreditation process can impact quality patient safety, but failed to identify any studies evaluating this relationship.

Missed nursing care is an indicator of poor quality. This review synthesizes what causes missed nursing care. The causes were grouped into three main themes: intrinsic resources, system structure, and social environment. The review also presents nurses' strategies to overcome challenges such as incorporating informal teaching into every patient interaction.

Similarly to practicing providers, medical and nursing students can experience second victim syndrome. This review sought to learn about if and how students are taught about second victims and what types of support are offered to them following an adverse event. The authors suggest that instruction about second victims could be included in curriculum on identifying errors.

Positive deviance (PD) in healthcare is an approach to learn from individuals or groups who are performing well above the norm in similar circumstances. This review identified 125 articles on PD. Studies focused on a variety of challenges such as hand hygiene and healthcare-associated infections. Before researchers and leaders embark on learning from positive deviants, a clear definition of PD and relevant performance measures must be identified.