Achieving zero preventable harm is an ongoing goal for healthcare organizations. This article describes one large, multistate community health system’s experience decreasing serious adverse events through implementation of high-reliability leadership, promoting human error prevention behaviors, and accelerating learning through a structured approach to cause analysis at both the individual and systems levels.

Reducing or preventing inpatient falls is a common focus of patient safety improvement efforts in hospitals. This study in three orthopedic and three geriatric wards describes multidisciplinary communication about falls prevention strategies. Risk assessments and categorization (e.g., high- or low-risk) were discussed in conjunction with strategies to focus on modifiable risk factors.

Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.

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.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

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Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.

Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.

Organizational culture can influence willingness to speak up about patient safety concerns. Based on focus groups and interviews with nurses, advanced practice providers, and physicians, this study found that the hierarchical culture of medicine presents a barrier to speaking up about safety concerns, but that certain factors (institutional, interpersonal, and individual) can modulate the impact of hierarchy. Interventions to promote speaking up behaviors should focus on engaging leaders across the institution and within the hierarchy.

Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.

Safety bundles are known to improve clinician adherence to guidelines and improve patient safety. This children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant deaths. Overall compliance with safe sleep guidelines increased from 9% to 72%. Three individual components also improved (head of bed flat, sleep space free of extra items, and caregiver education completed); one measure, centerline for infant in supine position, remained stable. The safe sleep bundle was shown to be effective in improving infant sleep environments.

Clinicians can experience adverse psychological consequences after making a mistake. This survey of 1,167 nurses found that social capital (both alone and in combination with psychological capital) has a significant impact on the severity of these adverse psychological outcomes.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.

This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 

Despite system-level interventions, medication administration errors (MAE) continue to occur. Nurses at an American hospital were trained in mindful thinking in an effort to reduce MAE. After three months, nurses who received the mindfulness training had fewer medication errors, and less severe errors, than nurses who did not receive the training. Mindful thinking was effective at reducing medication administration errors and the authors recommend trainings be part of nurses’ orientation and continuing education.

Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.

Peer review of radiation oncology patient treatment plans can help prevent harm and reduce errors. In this prospective blinded study, researchers generated treatment plans with simulated errors and randomly inserted these treatment plans into weekly chart rounds to assess the effectiveness of peer review on error detection. Overall detection rate of clinically significant problematic plans was 55%. The authors suggest that error detection could be significantly improved by shortening chart rounds and routine insertion of problematic plans into rounds.