Surgical safety checklists have been credited with improving perioperative patient outcomes, but numerous studies have shown implementation to be variable across settings and surgical specialties. This study aimed to redesign and reimplement the surgical safety checklist in two academic hospitals. Item completion and fidelity improved after reimplementation and exploratory analysis suggests improved patient outcomes (e.g., serious complications).

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

Inpatient falls are a persistent patient safety concern. In this study, researchers analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote patient monitoring can reduce inpatient falls. Findings indicate that remote patient monitoring (when combined with standard fall precautions) can reduce the incidence of falls and fall-related injuries, as well as decrease fall-related expenditures.

Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organization-wide standardized dashboards and summaries, thus allowing for local and systemwide improvements.

Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.

I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.

System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.

When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.

Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.

Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.

Effective apology for medical mistakes is a cornerstone for healing and improvement. This piece discusses the impact sincere and complete apologies may have on legal resolutions of patient harm. They discuss the current presence of apology laws at the state level and the limited role they play in protecting clinicians who err and apologize in a court of law.

… care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported …

Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.

Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.

Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.