Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.

Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.

Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.

Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.  

Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.

Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.

… of distress and increase providers’ coping skills. … Harrison R, Johnson J, McMullan RD, et al. Toward constructive change …

… speaking up behaviors. … Montgomery A,  , Lainidi O, Johnson J, et al. Employee silence in health care: Charting …

Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.

Feedback is an essential component of performance improvement and patient safety. Researchers conducted semi-structured interviews with emergency medical services (EMS) professionals in the United Kingdom about their perspectives on how feedback impacts patient care and safety. Findings highlight strong desire for feedback and concerns that inadequate feedback could inhibit learning from mistakes, limit professional development, and negatively impact patient safety.

… may result in improved patient safety. … Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on …

Children with intellectual disabilities may experience poor-quality care and be at higher risk for patient safety events. This cross-sectional study including patients admitted to two children’s hospitals in Australia found that children with intellectual disabilities had longer hospital stays and experienced more admissions with at least one clinical incident (e.g., medication incidents, documentation errors) compared to children without intellectual disabilities.

Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).

… is needed alongside individual-level interventions. … Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: Health …

… be an effective way to  enhance  patient safety.   … Janes G, Mills T, Budworth L, et al. The association between health …

In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.

… lack of disclosure training and guidance). … Sattar R, Johnson J, Lawton R. The views and experiences of patients and …

Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors, and the context in which these actions occur.  This systematic review identified 15 studies describing the use of team reflexivity within healthcare teams. Included interventions, most commonly simulation training  and video-reflexive ethnography, focused on the use of reflexivity to improve teamwork and communication. However, methodological limitations of included studies precluded the authors from drawing conclusions around the impact of team reflexivity alone on teamwork and communication.