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Cognition is a recognized human factor that can contribute to medical error. This systematic review explored whether mindful practice can improve diagnosis in healthcare. Of the 33 included studies, the majority were non-empirical; however, the authors tentatively conclude that mindful practice may be a promising method to improve diagnostic accuracy and reduce error.

A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.

Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.

This article describes the implementation of a peer support program for “second victims” in a US healthcare system. Following training, peer supporters assisted at-risk colleagues, raised awareness of second victim syndrome, and recruited others for training. The effectiveness of the training was assessed using the Second Victim Experience Support Tool. The most common event supported was inability to stop the progress of a medical condition, including COVID-19.

Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.

Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.

Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.

The goal of peer review is to provide clinicians with the opportunity to learn from errors. A multidisciplinary panel at one academic medical center established a new approach for physician peer review which incorporated a protected electronic portal for communication and engagement and a Just Culture peer review algorithm to identify opportunities for system improvements. The new approach decreased the average time necessary for full case review and increased provider engagement.

Patient-centered medical homes (PCMHs) are designed to be team-based, coordinated, accessible primary health care. This qualitative study explored patient perceptions about safety in PCMHs. Identified themes important to patient safety include communication with and between clinicians and trust in the care team, including being heard, respected, and treated as a whole person.

Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.

Health profession students are required to demonstrate competence in a variety of areas related to safe patient care. This article puts forth a recommendation to move beyond core competencies to improve patient safety and clinicians’ mutual safety.

Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.

While racial, ethnic, and gender biases have been widely documented at the system level, it has not been well documented at the individual physician level. This analysis of 4.5 million emergency department visits in the US showed variation in hospital admission rates among physicians, but an individual physician’s propensity to admit patients did not vary by patient sociodemographic group.

Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.