Schools of health are increasingly developing interprofessional courses on patient safety. This realist synthesis of the literature presents the contexts in which interprofessional education (IPE) does or does not improve students' attitudes towards patient safety, the methods of teaching and learning, and identifiable and potential outcomes.

Preventing patient falls in hospital settings is a patient safety priority. Set at one Veterans Health Administration (VHA) hospital, this study found that use of SmartSocks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced falls by more than 50% among patients determined to be at high-risk of falling.

… with providers, and medical decision-making within a racialized health system. Study participants reported … own knowledge and experiences, and feeling isolated as a result. …

Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.

Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.

Delivering health care in the home presents unique patient safety challenges. In this study, researchers identified significant associations between Joint Commission accreditation and measures of patient experience and patient safety with home health.

… BMJ Medicine … Pharmacists play a critical role in medication safety . This article evaluated the impact of a pharmacist-led information technology intervention ( PINCER … indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated …

Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.

Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

… PLoS Med … Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors ) among a subset of primary care practices in the United Kingdom …

Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.

Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.

Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.

… Am J Health Syst Pharm … Pharmacists play a critical role in ensuring patient safety in both inpatient … reported concerns about pharmacy staffing shortages . … Schneider PJ, Pedersen CA, Ganio MC, et al. ASHP National …