Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.

… JAMA Surg … Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This … including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for …

… J Nurs Care Qual … Inpatient falls are a persistent patient … analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote …

Electronic health records increase safety in many ways but are not without problems. In this survey, emergency department nurses reported that electronic health record (EHR) issues (downtime, workflow) negatively impacted patient safety such as documentation or orders placed on the wrong patient chart.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.

Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).

… Health Expect … Caregivers and family members offer a unique perspective on patient safety. In this study, …

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.

In the United States, women and birthing people of color experience disproportionately high rates of mortality and severe maternal morbidity (SMM). Researchers analyzed two years of incident reports (IR) to ascertain potential system issues contributing to SMM and racial/ethnic disparities at one hospital. Non-Hispanic Black individuals were over-represented in IRs, but there were no statistically significant differences in harm level.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.

Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.

Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.

Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.

Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

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.