Mitigating error and encouraging teamwork is essential in complex surgical environments. In this study, researchers found that surgical caps labeled with names and roles fostered a climate of safety and inclusion among perioperative clinicians.

High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.

Psychological safety promotes speaking up and error reporting in the workplace, and many system and individual characteristics interact to promote or hinder reporting behavior. This review highlights individual characteristics that encourage error reporting, (confidence and positive perception of self, the organization, and leadership) or create barriers (self-preservation associated with fear and negative perceptions of self, the organization, and leadership).

Healthcare-associated infections (HAIs) continue to be a preventable safety problem. This study explored the correlation between hospitals’ Leapfrog Hospital Safety Grade and Magnet designation on measures of patient safety, including healthcare-acquired infections (HAIs). The researchers found that Leapfrog safety scores were higher for Magnet-designated versus non-Magnet-designated hospitals – particularly for structural measures – but Magnet-designated hospitals did not have lower HAI rates.

Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.

The IHI Global Trigger Tool (GTT) is used to detect adverse events (AE) in hospitalized patients, but studies have shown variability in the types and rates of errors detected. In this study, researchers aimed to determine the accuracy of the GTT through a diagnostic test study. The GTT showed satisfactory sensitivity, specificity, and global accuracy for AE detection, but performed better when minor harm AEs were excluded.

Women often experience misdiagnosis and diagnostic delays due to process failures and implicit bias. This multicenter cohort study including 190 patients found that women were more likely to experience delays in diagnosis and misdiagnosis of inflammatory bowel disease, as compared to men. Researchers found that these inequities in misdiagnosis occurred across all healthcare settings (emergency department, primary care, gastroenterology, and hospital admission).

Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.

Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.

… across medical settings. This study of patients admitted to a surgical ward in Spain compared rates of AE in operated … patients. Operated patients were more than twice as likely to experience an AE compared with non-operated patients. The …

Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process. 

Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.

… A, et al. Leveraging a safety event management system to improve organizational learning and safety culture. Hosp …

… remote triage and assessment. Findings highlight the need to strengthen organizational resilience , develop and … elderly, vulnerable and homebound patients). … Wieringa S, Neves AL, Rushforth A, et al. Safety implications of …

… study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal …

While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.

… mobile apps, conversational assistants, and the internet to find information about health conditions or medications . In a follow up to an earlier study, researchers evaluated two approaches to … from conversational assistants . … Bickmore TW, Ólafsson S, O'Leary TK. Mitigating patient and consumer safety risks …

Defining and measuring patient safety is an ongoing challenge. This systematic review explored international approaches to defining serious reportable patient safety incidents. Findings indicate wide variation in terminology and reporting systems among countries which may contribute to missed opportunities for learning. Serious reportable patient safety events were commonly defined as being largely preventable; having the potential for significant learning; causing serious harm or having the potential to cause serious harm; measurable and feasible to report, and; running the risk of recurrence.

Clinicians can experience adverse psychological consequences after making a mistake. This survey of 1,167 nurses found that social capital (both alone and in combination with psychological capital) has a significant impact on the severity of these adverse psychological outcomes.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.