Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.

Blood transfusions errors can have serious consequences. In this retrospective study including 15 community hospitals, researchers identified high rates of unnecessary blood transfusions, primarily attributed to overreliance on laboratory transfusion criteria and failure to follow guidelines regarding blood management.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

Digital health tools are increasingly used across all areas of the healthcare system. In this study, researchers convened an interdisciplinary expert panel to identify patient safety concerns associated with emerging digital health technologies and to outline recommendations to address these concerns.

Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

The COVID-19 pandemic has disrupted healthcare delivery. This study reviewed data from a large medical professional liability company to explore guidance sought by physicians and dentists during the initial months of the pandemic. Providers’ questions and concerns primarily involved operations (e.g., access to personal protective equipment, liability coverage), patient care (e.g., guidance for screening patients), scope of practice, and use of telemedicine.    

The COVID-19 pandemic has resulted in numerous challenges for delivering health care to medically complex patients. This qualitative study explored how home-based primary care practices (HBPCs, which deliver care to individuals lacking access to traditional primary care) provided patient care during the pandemic. Strategies included increased use of virtual care, communication tools such as daily huddles, and mental health services for patients experiencing depression and isolation.

… care use and subsequent diagnoses among residents in a poor, urban area in the United Kingdom. Between March and … system diseases and type 2 diabetes.   … Williams  R, Jenkins DA, Ashcroft DM, et al. Diagnosis of physical and …

COVID-19 has upended the care seeking behaviors of patients and the ability to measure the full impact of the disease. This news story reports that patients with COVID may be dying at home due to coronavirus fears which is affecting the reliability of local tracking efforts.    

This commentary describes one academic medical center’s approach to “medical distancing” to mitigate the risk of virus transmission for patients and healthcare workers, and the effects on both patient care and medical education.

This pre–post study sought to examine whether a task force could reduce the risk of unprofessional behaviors at an acute care center. Certain types of negative behaviors declined, but the authors suggest that additional strategies are needed to enhance safety through professionalism.

Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.

… commentary describes the development and implementation of a patient safety curriculum in a pediatric primary care practice and the results of the …