Health care-associated infections continue to be one of the most common health care-related complications. This systematic review including 67 studies identified several cost-effective interventions addressing health care-associated infections, including screening high-risk individuals, universal decolonization in intensive care units, hand hygiene, environmental cleaning, and surveillance. The authors found limited evidence evaluating the cost-effectiveness of other strategies such as education and training or use of personal protective equipment.

Hand hygiene is known to be a critical part of effective infection prevention and control. This study examined the level of hand hygiene implementation using the WHO Hand Hygiene Self-Assessment Framework global survey and its drivers. There were 3,206 organizations from 90 different countries that responded. Over half of the participants indicated they had intermediate hand hygiene implementation, particularly those with higher county income levels and facility funding. Implementation of alcohol-based hand rub stations was an important system change associated with improved scores.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

… study. Patient Educ Couns. Epub 2021 Oct 30. doi: 10.1016/j.pec.2021.10.016 …

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

… J R Soc Med … This mixed-methods study analyzed patient … Wales: a mixed methods analysis for quality improvement. J R Soc Med. Epub 2021 Aug. doi: 10.1177/01410768211032589. …

The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.  

Methadone and buprenorphine are commonly prescribed to treat opioid use disorder, but their use presents patient safety risks. Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care stemmed from errors in dispensing practices (e.g. wrong patient, incorrect dose, incorrect formulation). Staff- and organization-related factors – such as not following protocols, poor continuity of care – contributed to more than half of the incidents.

This thematic analysis explored variations in the impact of hand hygiene interventions to prevent healthcare-associated infections. The analysis identified several directions for future research, including exploring ways to avoid the Hawthorne effect, embed the interventions into wider patient safety initiatives, and develop systematic approaches to implementation.

Presenteeism among healthcare workers can lead to burnout and healthcare-associated infections, but prior research has found that significant numbers of healthcare workers continue to work despite having influenza-like illness. This study surveyed 249 healthcare workers and 284 non-healthcare workers from 49 countries about their behaviors when experiencing influenza-like illness between October 2018 and January 2019. Overall, 59% of workers would continue to work when experiencing influenza-like illness, and the majority of healthcare workers (89.2-99.2%) and non-healthcare workers (80-96.5%) would continue to work with mild symptoms, such as a mild cough, fatigue or sinus cold.  Fewer non-healthcare workers (16.2%) than healthcare workers (26.9%) would continue working with fever alone.

Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.

This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency departments in England and Wales. The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. The authors identified three themes stemming from human factors that contributed to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when indicated), inappropriate response to diagnostic imaging, and failure to order diagnostic imaging. Potential interventions to address these contributors are briefly discussed.

This commentary recommends that health care structure the work environment to address conditions that allow for failure. The authors discuss how increased commitment to collective accountability for improvement will result in the robust infrastructure, proactive risk assessment, and cultural conditions needed to ensure patient safety.

The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.

The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.

… Journal of the Royal Society of Medicine … J R Soc Med … Investigators analyzed 132 incident reports …

Poor safety culture has been identified as a barrier to incident reporting. Researchers analyzed a sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System and found that blame was attributed to an individual in almost half of the reports. The authors suggest that successfully using incident reports to improve safety requires a shift to blame-free culture.

In the United States, patient safety is a required competency within residency training. Despite the dissemination of the WHO Patient Safety Curriculum internationally, little is known about its implementation in low- and middle-income countries. This cross-sectional survey study found that while 30 of 44 countries surveyed were considering implementing a patient safety curriculum, significant barriers to successful implementation persist.

According to this mixed-methods analysis of 8 years of data, the most common voluntarily reported incidents involving older primary care patients in England and Wales were related to medication errors and inadequate communication between providers. Many of these errors occurred during the transition home after hospital discharge. These data provide targets for further research to develop methods for improving safety in ambulatory care.

Since the inception of the patient safety movement, most research has focused on the inpatient setting. Although the focus on ambulatory safety has grown in recent years, little is known about adverse events in outpatient pediatric care. In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care patients from the England and Wales' National Reporting and Learning System over a 9-year period. Using descriptive and thematic analysis, researchers sought to identify the most common and serious event types, reasons these events occurred, and opportunities for improving safety. They found that about one third of 2191 safety incidents represented cases of severe harm. Based on their analysis, the authors conclude that efforts should focus on building safer systems for medication dispensing in community pharmacies, enhancing the triage process for sick children, and improving communication between providers and parents. An accompanying editorial discusses the value of incident reports with regard to improving care for pediatric primary care patients.