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.

Research has shown a robust safety culture improves patient outcomes, reduces length of hospital stay, and increases patient and staff satisfaction. As such, safety culture is increasingly being measured by healthcare organizations. This review sought to identify the factors measured by safety culture instruments in hospitals. The Hospital Survey on Patient Safety Culture and Safety Attitudes Questionnaire were the most frequently used instruments. Important factors include organizational, professional, and patient and family participation, although none of the instruments measured all three.

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.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

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.

Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.

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.

Pediatric patients are at particularly high risk for medication errors. This article describes the STAMP initiative (Safe Treatment and Administration of Medicine in Pediatrics) which aims to reduce pediatric inpatient prescribing and administration errors. The authors summarize the STAMP interventions originally implemented in 2017 and discuss the new interventions implemented during the COVID-19 pandemic (between July 2020 and August 2021), which led to sustained reductions in prescribing errors.

Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.

Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

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.