Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.

Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.

Fostering a culture of safety is an essential component of improving patient safety and health care quality. This systematic review of seven articles identified a negative relationship between job-related stress among nurses and patient safety culture. Studies also reported that factors such as fatigue, workload, burnout, and workplace violence contribute to job-related stress and resulted in decreased patient safety culture.

Error management training (EMT) encourages learners to make errors during training, and then engage in positive discussions about recognition of those errors. This commentary calls for increased use of EMT for surgical students and residents to promote error recovery.

Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.

Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.

Improving care transitions is a patient safety priority. Based on interviews with 21 nurses in Sweden, this study explored nursing concerns regarding transitions of care from inpatient to home healthcare settings in rural areas. Participants cited concerns regarding care coordination, communication, and logistics.

The IHI Global Trigger Tool (GTT) is used to detect adverse events (AE) in hospitalized patients, but studies have shown variability in the types and rates of errors detected. In this study, researchers aimed to determine the accuracy of the GTT through a diagnostic test study. The GTT showed satisfactory sensitivity, specificity, and global accuracy for AE detection, but performed better when minor harm AEs were excluded.

Adverse drug events (ADE) can result in patient harm, hospital admissions, and, in severe cases, death. This systematic review and meta-analysis estimates the prevalence of preventable ADEs resulting in emergency department visits or hospitalization, and the types and prevalence of ADEs and implicated drugs.

Operating room (OR) “black boxes”;– which combine continuous monitoring of intraoperative data with video and audio recording of operative procedures – are increasingly used to improve clinical and team performance. This study surveyed OR professionals in Denmark and Canada about safety attitudes and privacy concerns regarding OR black box use. Participants were primarily concerned with safety climate and teamwork in the OR and use of OR black boxes can support learning and improvements in these areas. The North American cohort expressed more concerns about data safety.

Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.

Efforts to embed patient safety content into defined post-graduate medical curriculum face challenges due to time, culture, and program resource demands. This statement provides detailed safety and quality content recommendations for maternal-fetal medicine fellows that focus on topics such as safety culture, event reporting, and disparities.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment. 

Empowering patients to ensure safe care is one component of patient engagement. This analysis of 456 patients found that self-efficacy increased patient engagement in their care and led to increased patient safety.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.