Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

… J Patient Saf Risk Manag … Racial and ethnic minoritized … safety determinants in ethnic patient groups. J Patient Saf Risk Manag. 2023;28(1):31-46. …

Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Medication-related adverse events (MRE) occur frequently during anesthesia care and more research into preventing them is needed. This article presents a descriptive analysis of the MRE reported to the Spanish Anaesthesia Incident Reporting System database during the decade from 2008 through 2017. Of the 1970 MRE identified, the highest number (42%) occurred during the administration phase, and a greater percentage of administration-related MRE resulted in harm to patients (44% as opposed to 31% over all 1,970 events). The authors identified patterns and specific causes of MRE that they suggest could be mitigated using proven systems solutions.

Auditing for compliance with safety practices is performed frequently in the health care setting, both for learning and feedback as well as for regulatory purposes. In this survey study involving boards of directors and hospital leaders from 89 acute care hospitals in the Netherlands, researchers sought to identify factors for effective auditing and provide suggestions for how hospital boards can use such auditing practices to inform governance.

This education study randomized medical students to learn about patient safety either through a text-based electronic module or a serious game activity with a didactic purpose. Students randomized to the game and the electronic module performed equally well on a patient safety knowledge assessment, and both groups performed better than students who did not have any patient safety education. Although students found the game more engaging, it also lasted about 3 hours compared to 1 hour for the text-based module.

In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.

This review examined the evidence base for reducing adverse events in hospitals. Investigators found sufficient evidence to support implementation of certain types of interventions, such as rapid response teams to reduce cardiac arrest and mortality rates, bundles and checklists to mitigate hospital-acquired infections, and pharmacist interventions to decrease adverse drug events. However, the overall evidence base for many of the patient safety interventions used by hospitals is weak.

The growing focus on enhancing health care safety has placed new demands on hospital leadership to implement improvement initiatives. Examining governance of patient safety in the emergency department, this systematic review found that robust tools for monitoring patient safety and reporting errors are lacking.

This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.

This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness.

In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.

Although 12-hour nursing shifts are common in the United States, this study found that only 15% of European nurses worked 12 hours or more. Similar to prior research, longer nursing shifts were associated with lower quality of care and compromised patient safety. This study also found that nurses working extended shifts reported more care left undone. Nurses who worked overtime, even if shift length was less than 10 hours, described similar concerns. The authors warn that policies to adopt standard 12-hour nursing shifts as a cost-effective way of maintaining nurse–patient ratios may contribute to burnout. A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse staffing and workload.

In this cluster randomized trial, a strategy that sought to improve nurses' hand hygiene by emphasizing team commitment and leadership engagement did achieve higher hand hygiene rates compared with a standard quality improvement approach. However, the overall rate of hand hygiene adherence remained poor in both groups.

Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.

This analysis of videotaped postoperative patient handoffs revealed that the majority of clinicians engaged in multitasking—handover of both equipment and clinical information—while transferring care. Such behavior violates the sterile cockpit concept and may be a source of error during handoffs.

Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.