Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.

Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.

Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.

… of AI that affect reliability. … Classen DC, Longhurst C, Thomas EJ. Bending the patient safety curve: how much can …

… family engagement in safety. … Bell SK, Bourgeois F, Dong J, et al. Patient identification of diagnostic safety …

… perceived organizational safety . … Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: Infusion task reallocation and safety perceptions in U.S. hospitals. Health Care Manage Rev. 2023;48(1):14-22 …

… the effects of COVID-19 on healthcare worker well-being. … Sexton JB, Adair KC, Proulx J, et al. Emotional exhaustion among US health care workers …

… J Patient Saf. … Psychological safety (PS) is integral to … metric for the ability to speak up in healthcare settings. J Patient Saf. 2022;18(6):513-520. …

Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).

… J Patient Saf … Teamwork is an essential component of patient … and during COVID-19: the good, the same, and the ugly…. J Patient Saf. Epub 2022 Aug 10. …

The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.

Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.

… J Perinatol … Patients in the neonatal intensive care unit … seven days of admission was 6.2%. … Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the … intensive care unit: a retrospective cohort study. J Perinatol. Epub 2022 Mar 4. doi: 10.1038/s41372-022-01359-9. …

… emotional, physical, and financial harm . … Bell SK,  Dong J, Ngo L, et al. Diagnostic error experiences of patients and …

… care professionals (such as chaplains, social workers). … Vogus TJ, Wilson AD, Randall K, et al.  We're all in this …

Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.

This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.

… J Patient Saf Risk Manag … Effective communication between … birth events: experiences of parents and clinicians. J Patient Saf Risk Manag. 2021;26(5):200–206. …