Patients evaluated by a rapid response team at night were less likely to be transferred to the intensive care unit and more likely to die in the hospital compared to patients evaluated during the daytime. A previous WebM&M commentary discussed a preventable adverse event occurring in part due to less intensive nighttime staffing.

Discordance between patient preferences for end-of-life care and documentation of their wishes is a common problem in hospitals. Such events have been described as silent misdiagnoses and may be classified as medical errors. This audit study across 16 hospitals in Canada quantified how often medical orders for life-sustaining treatments do not match patient preferences. Only 2% of patients who reported a preference for cardiopulmonary resuscitation (CPR) had CPR withheld in their medical orders; whereas, 35% of patients who wished to forgo CPR had orders to receive it in the event of an arrest. This mismatch represents a considerable source of potential overtreatment, which may result in numerous adverse downstream effects. A previous WebM&M commentary discussed tools for eliciting end-of-life preferences.

Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.

A positive safety culture has been linked to improved staff satisfaction as well as a lower incidence of errors. This study, conducted in 23 Canadian intensive care units (ICUs), sought to examine the relationship between safety culture and families' satisfaction with care. The authors found a strong positive correlation between safety culture and family satisfaction with care among a subset of patients who had prolonged and ultimately fatal ICU stays. This finding implies that families of patients who have lengthy hospitalizations are affected by the safety and organizational culture of the units where their loved ones are being cared for and that improving safety culture may also improve patient and family satisfaction with care.

This survey of Canadian intensive care units found that larger units and units directed by full-time intensivists had more positive safety culture scores.