Digital health tools are increasingly used to support the delivery of safe healthcare. This scoping review characterized 13 articles exploring the use of digital interventions intended to support patient safety among pediatric patients and their parents. Interventions were commonly delivered through mobile applications, web-based technologies, computer kiosks, and electronic health records, and focused on patient safety event prevention and risk management.

Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).

Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.

Overlapping surgery – when surgeons schedule distinct procedures on different patients concurrently – has raised safety concerns but recent studies have not found significant differences in perioperative outcomes. This retrospective cohort study including over 87,000 surgical cases found that overlapping surgeries increased operative times but did not lead to increased in-hospital mortality, adverse events, or readmission rates when compared to nonoverlapping cases.

In medical education, the “hidden curriculum” refers to the influence of offhand comments, behaviors, and attitudes of senior clinicians on the formation of a student’s professional identity. This scoping review identified five papers examining the hidden curriculum in pharmacy education. The studies identified several approaches to address the hidden curriculum during pharmacy training, such as better integration of formal and informal training activities, encouraging positive mentor:mentee relationships between students and practicing pharmacists, and cultivating professionalism.

Studies have shown that physicians are less likely to report errors and adverse events when compared to other clinicians. To increase the number of self-reports by surgeons, this hospital implemented a program of financial incentives. The incentive program led to an increase in reporting by physicians and physician assistants.

Standardized and virtual patient encounters are often used to develop medical and nursing students’ diagnostic reasoning. Through educational interventions including virtual patients, medical students increased their diagnostic accuracy compared to baseline and the completeness and efficiency in the differential diagnosis increased.

… and emphasizing physician authority over the patient. … Park J, Saha S, Chee B, et al. Physician use of stigmatizing language in patient …

Physician language choice can reflect implicit biases, which can compromise patient care. In this study, researchers conducted a content analysis of 600 clinic notes to explore how physicians communicate disbelief in medical records and racial and gender differences in the use of such language. Three linguistic features suggesting disbelief were identified: (1) use of quotes (e.g., patient had a “reaction” to the medication), (2) use of judgement words – such as “claims” or “insists” – that imply doubt, and (3) reporting patient experiences as hearsay (e.g., “the patient reports that the symptom started yesterday"). The researchers found that these linguistic features were more common in notes written about Black patients compared to white patients; no gender differences were identified.

Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.

Patients and families are essential partners in identifying and preventing patient safety events. This meta-analysis found that patient and family involvement interventions can significantly reduce adverse events, decrease hospital length of stay, increase patient safety experiences, and improve patient satisfaction.

… COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between … percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that … of SARS-CoV-2 among frontline health care personnel in a multistate hospital network - 13 academic medical centers, …

… at Emergency Department (ED) visits within 30 days of a hospitalization for acute myocardial infarction (AMI) to … linked to probable missed diagnoses. Within 30 days of a subsequent hospitalization for AMI, common ED discharge … harms annually in the United States.   … Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in …

This study merged inpatient discharge data with annual survey data from the American Hospital Association and found that private patient rooms were significantly associated with fewer hospital-acquired MRSA infections; however the effect of private rooms is disproportionate across hospitals. Hospitals with fewer private rooms stand to see the greatest decrease in MRSA infections from adding additional private rooms. These findings can assist hospital administrators making decisions about facility design and renovation.

This review synthesized research exploring how operational failures (e.g., distractions, situational constraints) in primary care affect the work of primary care physicians. The literature suggests that operational failures are common, and the gap between what physicians perceive that they should be doing and what they were doing (“work-as-imagined” vs, “work-as-done”) is largely attributed to operational failures over which the primary care physicians had limited control. The authors suggest that future research focus on which operational failures have the highest impact in primary care settings in order to prioritize areas for targeted improvement.

This study compared an artificial intelligence (AI)-based early warning system using machine learning with conventional trigger methods for predicting deterioration among hospitalized patients, defined as in-hospital cardiac arrest resulting in ICU admissions. The AI system accurately predicted deterioration and was more accurate than conventional methods, demonstrating its potential effectiveness in EHR-based rapid response systems.

Adverse events can have significant psychological impacts on the providers involved and involvement in medical errors can increase risk of burnout among second victims. This study describes the nurse utilization of the Resilience in Stressful Events (RISE) peer support program. The authors found high awareness of the program among nurses, but low utilization. Nurses who had used the program reported greater resilience, but more burnout than those who had not.

Patients and families are critical partners in identifying and preventing patient safety events. A systematic review found willingness among patients and families engage in safety activities, but barriers such as limited patient/family knowledge, poor communication, and lack of systems-level efforts supporting patient and family engagement may hinder effective engagement.