Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.

Artificial intelligence (AI) is increasingly used in healthcare, but concerns have been raised that it can exacerbate existing disparities because of underlying biases in AI tools. In this observational study, researchers evaluated biases in clinician versus AI chatbox responses to 19 clinical vignettes involving cardiology, emergency medicine, rheumatology, and dermatology. Findings indicate that both AI chatboxes and clinicians provide different clinical recommendations based on a patient’s gender, race/ethnicity, and socioeconomic status under certain clinical scenarios.

The American Academy of Pediatrics' Policy Statement, "Preventing Home Medication Administration Errors", called for improving medication safety at home for children with medical complexity. This article describes a toolkit for pediatricians to support implementation focusing on four interventions: establishing practice-based error reporting systems, standardizing medication reconciliation, improving communication, and integrating resources for patients and families. Of particular importance is the use of health literacy-informed, culturally sensitive resources.

Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

Interest in testing ChatGPT as a clinical tool is increasing. This study asked ChatGPT to provide a differential diagnosis, diagnostic testing, final diagnosis, and care management for 36 previously published clinical vignettes. ChatGPT had an overall accuracy of 72%, with the highest level of accuracy at the final diagnosis stage (77%).

Delayed diagnosis and treatment of stroke leads to adverse patient outcomes. This cross-sectional study identified gender disparities in the treatment of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS), with women being less likely to be routed directly to comprehensive stroke centers compared with men, despite having more significant stroke syndromes.

Community pharmacists are perhaps the last line of defense in preventing medication errors in the outpatient setting; therefore, ensuring a strong safety culture is critical. This review identified 11 studies reporting on safety culture using the AHRQ Community Pharmacy Survey on Patient Safety Culture. Pharmacists and pharmacy staff rated overall patient safety highly, but more than half identified workload as a concern.

Despite extensive research and interventions, medication prescribing errors in hospital continue to occur. This review sought to identify prescribing errors and factors that facilitate or prevent prescribing errors. Prescribing errors were categorized as prescriber-, prescription-, technology-, or organization-related, or unclassified. Most errors were organization-related. The authors recommend examining facilitators and barriers to prescribing safety prior to implementing new interventions.

Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

Workers who experience psychological safety in their organization are more likely to speak up about safety concerns. This study reports on how trust and psychological safety interact to increase error reporting. Results indicate that trust in leaders encouraged error reporting and psychological safety encouraged learning from mistakes.

Physical and verbal violence against healthcare workers has been identified as a sentinel event by the Joint Commission. In this secondary analysis of survey data on workplace violence (WPV), researchers explored which attributes of patient safety culture may predict healthcare workers’ experiences of WPV and burnout. Better teamwork and staffing were among the attributes associated with lower risk of WPV.

In response to concerns about workplace violence (WPV) directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations to increase organizational awareness of this risk. This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ burnout and patient safety. As anticipated, WPV increased nurse burnout, but unexpectedly, a strong WPV-reporting culture also increased the negative effect of WPV on burnout.

Safety culture has been shown to be associated with nursing home quality indicators such as discharge to community and injuries related to falls and catheters. Numerous surveys exist to measure safety culture. This review identified seven measurement tools, and the most frequently used tool was the Nursing Home Survey on Patient Safety Culture. The Hospital Survey on Patient Safety Culture, Safety Attitudes Questionnaire, and Modified Stanford Patient Safety Culture Survey Instrument were also used.

Research into the impact of racism on health outcomes has increased in recent years, but there has been less emphasis on ageism or the intersection of ageism and racism. This commentary highlights the ways racism (e.g., clinical algorithms), ageism (e.g., proposed measures to ration care) and the intersection of the two (increased morbidity and mortality of COVID-19 on older people of color) impacts health outcomes. Recommendations for current clinicians and health profession educators are provided.

Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.

COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.