Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.

… and analysis specific to marginalized patient groups. … Wade C, Malhotra AM, McGuire P, et al. Action on patient safety can reduce health …

… for practical action are described. … Amalberti R, Staines A, Vincent C. Embracing multiple aims in healthcare improvement …

… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these … to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J …

… effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other … or other ancillary services. … Marang-van de Mheen PJ, Vincent C. Moving beyond the weekend effect: how can we best …

… Arch Dis Child … In the second of a two-part series , using examples from newborn units, the authors present a framework for supporting practitioners in low-resource … and (4) enhancing responses to hazardous situations. … Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child.  Epub …

… proactively identify patient safety risks. In the first of a two-part series , the authors draw on the   Systems … framework   to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient …

Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.  

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.

The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.

This analysis of 220 national incident data from England and Wales’ National Reporting and Learning System  sought to identify safety concerns experienced by children on long-term ventilation at home. The most common problems were with the equipment and devices (e.g., faulty or damaged equipment) or procedures and treatment (e.g. tracheostomy tube becomes dislodged). The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change or hospital admission. Identified contributory factors involved the patients, staff performance, family caregivers, equipment, organizational, and environmental features.

… did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment … testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer. …

… BMJ Qual Saf … BMJ Qual Saf … Health care is considered a high-risk industry due to clinical, administrative, … economic, and regulatory stressors. This review explores a range of approaches to managing the safety of patients in …

… test, and implement assessments of nontechnical skills. A related editorial discusses the findings of this systematic …

… as measuring the impact of residency training programs. In a past PSNet interview , Dr. Tejal Gandhi, president of the … Leape Institute, discussed improving patient safety at a national level. …

… by the Imperial College Mortality Surveillance System (a national hospital mortality surveillance system that … trusts. On average, mortality risk decreased after a trust received a mortality alert. However, the authors conclude that random …

… safety … BMJ Qual Saf … This study examined the impact of a safety assessment intervention across nine public health …

… patients and families in assessments and investigating a longer time period to understand the full patient care …