Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.

There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.

Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 

The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.

This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.

… and whistleblower complaints. … Kok J, Wallenburg I, Leistikow I, Bal R. The doctor was rude, the toilets are dirty. …

… care quality and safety. … de Kam D, Kok J, Grit K, Leistikow I, Vlemminx M, Bal R. How incident reporting systems can stimulate social …

… how resilience and learning from things that go right (i.e., Safety-II ) can influence interactions between …

Patient and family engagement enriches both incident reporting and adverse event investigations. These qualitative interviews with Dutch hospital managers highlight two assets patients and families offer during incident investigations: they provide details hospital staff cannot otherwise capture and the opportunity to regain trust. An Annual Perspective discussed novel approaches to engaging patients in their safety.

… Err Is Human raised awareness of patient safety. Providing a short history of patient safety work, this commentary …

Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.

Experiences from national incident reporting systems can help inform design of other programs. This commentary describes the Dutch national reporting system effort to encourage individual hospital learning through collecting comparative data on activities locally, assessing the reports, and monitoring improvements.

… Int J Radiat Oncol Biol Phys … Implementation of a safety system that included a voluntary error reporting system and structured checklists … oncology department. … Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program …

… had to intervene to prevent medication errors in a children's hospital, despite the presence of a computerized provider order entry system. …

… criteria into question. … Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. Functional decline associated with …

This commentary presents ambiguity, autonomy, complexity, and visibility as challenges to improving safety and makes recommendations to address them.

… Surgery … Surgery … Communication failures are a well-characterized source of errors in the operating room. … in surgical patients, and in this study, implementation of a teamwork training program was associated with fewer …