Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.

While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.

A “just culture” balances organizational responsibility and individual accountability after an error occurs. This integrative review of 16 articles identified four concepts critical to implementing a “just culture” in healthcare settings – leadership commitment, education and training, accountability, and open communication.

Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.

… Am J Med Qual … The goal for health care organizations to attain … training, and safety culture . … Merchant NB, O'Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. 10.1097/JMQ.0000000000000086 …

Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.

A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.

Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

… fatigue for team leaders. … Grailey K, Leon-Villapalos C, Murray E, et al. Exploring the factors that promote or …

… and suggest further research into the topic. … Grailey KE, Murray E, Reader T, et al. The presence and potential impact …

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

… Am J Health Syst Pharm … When patients are admitted to the … of delirious or mechanically ventilated patients. Am J Health Syst Pharm. …

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

This article describes the implementation of a new system for identifying, communicating, and resolving safety reports pertaining to COVID-19 in one academic tertiary care center through the use of electronic safety reporting systems and daily huddles.

This study found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.

Rapid assessment procedures (RAP) describe a group of methods for studying organizational processes, practices and implementation. This study used RAP to evaluate the implementation of a package of patient safety interventions in intensive care units at four academic medical centers. The RAP approach included developing evaluation questions with stakeholder input, integrating implementation science into field guides and analytic tools, using a multidisciplinary evaluation team, building trust with the sites, engaging sites in participatory data collection, rapid team analysis of data sources, and validating findings with the sites. The RAP approach identified barriers and facilitators to successful intervention implementation and produced contextually-rich information using robust methods within a short timeframe. The authors conclude that this approach is particularly useful for learning health systems because it engages stakeholders in uncovering new insights.

Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.

Early warning systems and trigger tools are frequently used in inpatient settings to identify clinical deterioration and prevent adverse events in pediatric populations, but their use in community settings to improve illness detection and time to treatment is less common. The article discusses a consensus workshop, the goal of which was to develop the “severe illness getting noticed sooner” (SIGNS-for-kids) tool to empower parents and caregivers by identifying specific cues of severe illness in infants and children. The panel, comprised of parents and healthcare experts, identified five cues: (1) behavior, such as reduced interaction or lack of movement, (2) breathing, including noticeable breathing or long pauses between breaths, (3) skin, such as jaundice or blueish skin/tongue, (4) fluids, such as persistent vomiting or lack of urine, and (5) response to rescue treatments, or deterioration despite use of usually effective treatment.

"Never events" are serious but generally preventable patient safety incidents. This study surveyed general practitioners in the UK to assess the incidence of specific never-events in those practices, and whether practitioners agreed with the specific events being designated as a never-event. The most commonly reported events were not investigating abnormal test results (45% of practices) and prescribing despite documented adverse reactions (65% of practices); however, these events were also less likely to be designated "never events" by respondents.