Clinical decision-making can be influenced by both individual and team factors. This article describes the de Groot Critically Reflective Diagnoses Protocol (DCRDP), which can be used to evaluate how group dynamics and interactions can influence collective clinical decision-making. Transcripts of recorded decision-making meetings can be coded based on six DCRPD criteria (challenging groupthink, critical opinion-sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation), which identify teams that are interactive, reflective, higher functioning, and more equitable.

This article describes the use of a rapid-cycle in-situ simulation (ISS) program to facilitate identification and resolution of organizational and systems-level safety threats (i.e., latent safety threats) involving a possible COVID-19 case. Identified threats fell in four domains: personnel, personal protective equipment, supply/environment, and communication. Most participants felt better prepared to provide care after the ISS training.

Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.

Diagnostic error has yet to be formally integrated into graduate medical education. This commentary describes the design, implementation, and evaluation of a resident curriculum on diagnostic errors that explored medical decision making, critical thinking skills, and how to provide feedback and support for second victims.

Correct identification of patient specimens is crucial to timely and accurate diagnosis. This pre–post study demonstrated substantial improvements in already low rates of patient specimen identification errors following each of three successive strategies: discarding improperly labeled specimens, using barcodes, and automating specimen labeling.

This evaluation of the Transforming Care at the Bedside initiative—a collaborative intended to drive engagement of bedside nurses in enhancing safety through unit-based quality improvement projects—found highly positive perceptions of the program and evidence of widespread implementation of new innovations.

Most studies examine handoffs from the operating room (OR) to the intensive care unit (ICU). However, this review identified potential safety concerns during transitions in the opposite direction—from ICU to OR—to highlight risks related to coordinating these patient transfers. The authors include a checklist to enhance the safety of such transitions.

This study involved nurses, physicians, and pharmacists in a collaborative process to design and implement a high-alert medication list at six Singaporean hospitals. Multiple interventions were implemented to improve safety of these medications, resulting in a significant reduction in adverse drug events.

This article discusses how one children's hospital used patient safety rounds to identify 191 issues in its first year and then took measures to resolve them.

This review examined how publicly reported performance data affect quality of care and found that, although releasing such data stimulates quality improvement activities, the impact on clinical outcomes remains unclear.

The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability of the incidents. They found that the surgical events increased average lengths of stay by 9.9 days and have a lower level of preventability than other types of adverse events.