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.

Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.

… types of healthcare professionals. … Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in …

… in fidelity or did not assess fidelity. … Lo L, Rotteau L, Shojania K. Can SBAR be implemented with high fidelity and …

Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.

… nurses, primary care and other essential workers. … Schiff G, Shojania KG. Looking back on the history of patient safety: …

… strengthening dual diagnosis detection. … Calder LA, Perry J, Yan JW, et al. Adverse events among emergency department … study. Ann Emerg Med. Epub 2021 Feb 23. doi: 10.1016/j.annemergmed.2020.12.012. …

The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.

Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.

This commentary discusses the two ‘gold standard’ research methods used to identify adverse events– retrospective record review and prospective surveillance using triggers. The authors note that these approaches have served to demonstrate the scope of the patient safety problem and to engage clinicians, managers, researchers and policy makers. However, looking forward, they advocate moving away from the imperfect gold standard of adverse event rates and embracing more specific measures of important safety problems.

Medication reconciliation aims to prevent adverse events after hospital discharge. In this cluster randomized trial, researchers evaluated the impact of an electronic medication reconciliation intervention involving automatic integration of community drug data and found that this process reduced medication discrepancies but did not reduce adverse events. 

An international group of educational and health system leaders, educators, front-line clinicians, learners, and patients convened to create a list of actionable strategies that organizations can use to better integrate Quality Improvement Patient Safety (QIPS) education with clinical care. A framework and list of concrete examples describe how groups can get started.

The AHRQ Patient Safety Indicators (PSIs), which are used to screen administrative data for patient safety events, have been revised in response to the new ICD-10 coding system. This study sought to validate the accuracy of ICD-10-based PSIs for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program reference standard. Although the PSIs had relatively high negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an adverse event), the overall accuracy was not sufficient to warrant using PSIs as the sole strategy to detect adverse events.

The just culture paradigm shifts the response to error from a retrospective focus on blame to the system that contributed to the incident. This commentary describes one hospital's strategic and operational approach to just culture development and the results of the initiative.

This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

This prospective study used a trigger tool approach to identify potential adverse events among hospitalized patients in real time. Researchers found widely varying adverse rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible for some of the variation in observed events. These results underscore the challenge of accurate adverse event surveillance.

… safer health care systems. … Liu JJ, Rotteau L, Bell CM, Shojania KG. Putting out fires: a qualitative study exploring …

Evidence-based medicine has generated some controversy in quality and safety circles. The commentary highlights weaknesses in the science of evidence-based medicine and suggest that a broader systems-based approach is needed to inform health system redesign and improvement work.

Preventing adverse events after hospital discharge remains a top patient safety priority. In this randomized controlled trial, researchers found that the implementation of an electronic discharge communication tool did not significantly reduce death or readmission within 90 days of discharge.

… the International Society for Quality in Health Care … Int J Qual Health Care … For the first time, the World Health …