Inpatient falls are a persistent patient safety concern. In this study, researchers analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote patient monitoring can reduce inpatient falls. Findings indicate that remote patient monitoring (when combined with standard fall precautions) can reduce the incidence of falls and fall-related injuries, as well as decrease fall-related expenditures.

Schools of health are increasingly developing interprofessional courses on patient safety. This realist synthesis of the literature presents the contexts in which interprofessional education (IPE) does or does not improve students' attitudes towards patient safety, the methods of teaching and learning, and identifiable and potential outcomes.

In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.

Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.

Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.

Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Medication errors in pediatric patients can have serious consequences. This systematic review identified three studies examining interventions to improve medication safety in pediatric inpatient settings. Although the three interventions – a mnemonic device, a checklist, and a specific prescribing round involving a clinical pharmacist and a doctor – reduced prescribing errors, the studies did not assess weight-based errors or demonstrate reductions in clinical harm.

Missteps in the labeling and registration of child injury as abuse can result in harm for patients and families. This article discusses the impact of implicit bias on reporting actions and shares tactics to minimize the influence of cognitive error on recognizing and reporting of child mistreatment.

In response to the increase in opioid deaths, the Centers for Disease Control and Prevention (CDC) released the Guidelines for Prescribing Opioids for Chronic Pain in 2016, with an update released in 2022. This study reports on the CDC Opioid QI Collaborative which was launched to identify successful evidence-based strategies for implementing the guidelines. The challenges and strategies described in the publication can be used by health systems to accelerate implementation of the guidelines.

Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.

… Am J Health Syst Pharm … Pharmacists play a critical role in … reported concerns about pharmacy staffing shortages . … Schneider PJ, Pedersen CA, Ganio MC, et al. ASHP National … Settings: clinical services and workforce-2021. Am J Health Syst Pharm. 2022;79(18):1531-1550. …

Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.

Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.

Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.

… issues identified by parents. … Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with …

… J Appl Res Intellect Disabil … Children with intellectual … both patients and their parents. … Ong N, Long JC, Weise J, et al. Responding to safe care: Healthcare staff … in hospital. Implications for practice and training. J Appl Res Intellect Disabil. 2022;35(3):675-690. …

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

… develop a set of “implementation patient safety indicator(s) sets” to monitor the extent to which an RLS has been … to successful implementation. … Kuske S, Willmeroth T, Schneider J, et al. Indicators for implementation outcome …