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

Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.

Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.

Providers who are involved in a medial error may experience a range of negative emotions and utilize a variety of coping mechanisms following the error. The authors update their 2010 systematic review on medical professionals’ coping with medical error and apply their Recovery from Situations of Error Theory (ReSET) model. The ReSET model provides a basis to develop and evaluate interventions to reduce feelings of distress and increase providers’ coping skills.

When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.

… may result in improved patient safety. … Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis. Am J Surg. Epub 2022 …

Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.

Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

Many organizations have implemented interventions to support healthcare professionals after involvement with a medical error. Healthcare professionals who completed a proactive, resilience-based development program reported the program as useful in preparing them to cope with errors; however, they also recommend that a systems approach to increasing resiliency is needed alongside individual-level interventions.

Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).

Medication errors represent a significant source of preventable harm. This large meta-analysis, including 81 studies, found that approximately 1 in 30 patients is exposed to preventable medication harm, and more than one-quarter of this harm is considered severe or life-threatening. Preventable medication harm occurred most frequently during medication prescribing and monitoring. The highest rates of preventable medication harm were seen in elderly patient care settings, intensive care, highly specialized or surgical care, and emergency medicine.

The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  

This study evaluated the impact of an electronic decision support tool comprising a comprehensive drug review to support deprescribing and reduce polypharmacy in elderly adults. Results indicate that the tool did reduce the number of prescribed drugs but did not significantly reduce unplanned hospital admissions or death after 24 months.

… error disclosure. The 15 included studies highlighted a misalignment in attitudes and expectations between patients … lack of disclosure training and guidance). … Sattar R, Johnson J, Lawton R. The views and experiences of patients … professionals on the disclosure of adverse events: A systematic review and qualitative meta-ethnographic …

To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.

"Never events" are serious but generally preventable patient safety incidents. This study surveyed general practitioners in the UK to assess the incidence of specific never-events in those practices, and whether practitioners agreed with the specific events being designated as a never-event. The most commonly reported events were not investigating abnormal test results (45% of practices) and prescribing despite documented adverse reactions (65% of practices); however, these events were also less likely to be designated "never events" by respondents.

The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.

… adults. Physicians and patients alike struggled to achieve a balance between underinvestigating health concerns and …

Adverse events reported by patients are often different and more expansive than safety hazards identified by health care providers. Researchers elicited adverse events from a nationally representative sample of British outpatients. About 8% of patients reported an adverse event, which were frequently problems with medications, accessing care in a timely way, and diagnostic errors.

… by the Imperial College Mortality Surveillance System (a national hospital mortality surveillance system that … trusts. On average, mortality risk decreased after a trust received a mortality alert. However, the authors conclude that random …