COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.

Disclosure of adverse events to patients and families is an important component of safety culture. AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure process as well as peer support for healthcare providers (HCP) involved in the adverse event. This study aimed to identify associations with CANDOR implementation and HCP job satisfaction. Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in leadership, a novel finding not previously reported.

Prediction models are increasingly used in healthcare to identify potential patient safety events. This systematic review including 25 articles identified several challenges related to electronic health record (EHR)-based prediction models for adverse drug event diagnosis or prognosis, including adherence to reporting standards, use of best practices to develop and validate prediction models, and absence of causal prediction modeling.

Medication timing errors can lead to too-frequent or missed doses of medications and cause patient harm. This systematic review including 23 articles found that medication administration timing errors (defined in the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur in up to 72.6% of medication administration errors.

… worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and …

National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment. 

Adverse drug events (ADE) can result in patient harm, hospital admissions, and, in severe cases, death. This systematic review and meta-analysis estimates the prevalence of preventable ADEs resulting in emergency department visits or hospitalization, and the types and prevalence of ADEs and implicated drugs.

Transitions of care can increase risks for patient safety events. This systematic review examined the effectiveness of interventions aimed to increase patient safety during transitions of care between the hospital and home. The authors identified several interventions from previously published studies which increased patient safety and/or patient satisfaction and identified factors that contribute to effective transitions of care (i.e., nurse follow-up, pre-discharge patient education, and contact with local healthcare services).

I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.

Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.

Medication errors in pediatric patients can have serious consequences. This systematic review identified three studies examining interventions to improve medication safety in pediatric inpatient settings. Although the three interventions – a mnemonic device, a checklist, and a specific prescribing round involving a clinical pharmacist and a doctor – reduced prescribing errors, the studies did not assess weight-based errors or demonstrate reductions in clinical harm.

Ensuring patients have an understanding of their diagnoses and care plan is a critical component of patient engagement and can improve safety. Using semi-structured phone interviews and electronic health record (EHR) review, this study examined patient understanding about their inpatient care and discharge plan. Although the majority of patients (>90%) felt confident in their knowledge of their diagnosis and treatment plan, chart review indicated that only 43% to 64% correctly recalled details about their diagnosis, treatment, post-discharge treatment plan, and medication changes.