Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.

People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

… J Surg Res … While interoperative deaths (IODs) are rare, … This study analyzed five years of data on IODs from a large academic medical center. The authors describe three … processes. … Dorken Gallastegi A, Mikdad S, Kapoen C, et al. Intraoperative deaths: who, why, and can we prevent …

“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.

… arose during the pandemic. … Geerts JM, Kinnair D, Taheri P, et al. Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. JAMA Netw Open. 2021;4(7):e2120295. …

Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.  

This study evaluated trauma readiness among surgical residents following trauma surgery training and its impact on critical errors. Resident trauma readiness index increased significantly following the training, and training resulted in fewer critical errors committed by residents when compared with practicing surgeons. The trauma readiness index may help identify surgeons who would benefit from additional follow up training.

… study combined survey data from resident physicians with a comparison of process maps from three academic medical …

Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.

… Journal of general internal medicine … J Gen Intern Med … State-based prescription drug monitoring … to enhance existing efforts to curb the opioid epidemic . A WebM&M commentary highlighted the utility of prescription …

Home health care safety has historically received less attention than ambulatory or inpatient safety. This study reviewed safety hazards involving home infusion pumps in the United Kingdom. Device malfunctions were the most common safety hazard identified, and they were challenging for patients and caregivers to quickly or effectively address.

… effects of an antibiotic-resistant infection for a health care practitioner were vividly illustrated in a PSNet perspective . …

… hospitalized patients, adverse drug events (ADEs) are a common and serious source of patient harm. Medication … time of hospital admission reduces preventable ADEs and is a National Patient Safety Goal . In this three-arm, …

… , mainly due to lapses in communication. Implementation of a standardized approach to handoffs may help improve patient … pre–post intervention study examined the impact of a multicomponent handoff intervention consisting of … process and did not adversely impact nursing workflow. A previous Annual Perspective highlighted safety issues …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Patient falls represent a serious source of preventable harm, yet mitigating the fall …