Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.

Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.

… BMJ Medicine … Pharmacists play a critical role in medication safety . This article evaluated the impact of a pharmacist-led information technology intervention ( PINCER ) among a retrospective cohort of 56.8 million National Health …

… J Obstet Gynecol Neonatal Nurs … Cesarean delivery can lead … of labor before and after results were published from a large, randomized trial (Randomized Trial of Induction … inductions at 39 weeks to reduce the likelihood of a cesarean. Findings indicate that physician attitudes about …

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor. 

Real-time use of artificial intelligence in the operating room allows surgeons to avoid or immediately address intraoperative adverse events. This review summarizes 13 articles published since 2010 that report on the use of artificial intelligence to predict intraoperative adverse events. Most studies used video and more than half were intended to detect bleeding.

While preventable physical harm, such those from as wrong-site surgery or medication errors, have been the main focus of the patient safety movement, less attention has been paid to preventable psychological, or dignitary, harms. In this commentary, the authors present how dignitary harms do, and do not, fit into the patient safety field and how they can be addressed.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Psychological safety is a cornerstone of high reliability organizations (HROs). This children’s hospital developed two scales (trust in team members and trust in leadership) and one composite measure (local learning) to measure staff psychological safety and evaluate the effectiveness of their transition to high reliability. More than 4,500 health system staff completed the survey; results indicate the two scales are strongly associated with the composite measure.

Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

In 2017, the World Health Organization (WHO) introduced the third Global Patient Safety Challenge, Medication Without Harm. Interviews, focus groups, and document analysis were conducted at four UK hospitals to evaluate how they were addressing the domains and priority areas laid out in the WHO’s Patient Safety Challenge. Although all areas were addressed, additional focus is needed on patient and public involvement, transitions of care, and polypharmacy.

… Br J Gen Pract … The UK’s National Health Service (NHS) is … access to and efficiency of care are discussed.   … Turner A, Morris R, Rakhra D, et al. Unintended consequences of online consultations: a …

Surgical safety checklists (SSCs) have been shown to improve patient outcomes and reduce complications. In this study, postoperative mortality and increased days alive and out of hospital were measures for surgical patients in the 18-month period prior to implementation of the SSC and the 18-month period following implementation. Changes in mortality and days alive and out of hospital during these time periods were indistinguishable from longer-term trends. Researchers noted Māori patients had worse outcomes than non-Māori patients.