Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.

The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.

… J Hosp Med … Improving diagnosis in pediatrics is an ongoing …

Debriefing after clinical events is an important opportunity for critical learning, process improvement, and enhancing team communication. This systematic review of 21 studies synthesized findings regarding the attributes and evidence supporting the use of clinical debriefing tools. While all of the evaluated tools included points related to education and evaluation, few tools included a process for implementing change or addressed staff emotions. The authors include recommendations for clinicians, educators and researchers for teaching, implementing and evaluating clinical debriefing tools.

Patients and clinicians may hold implicit gender biases and rate women clinicians more negatively. In this study, adverse event reports written about residents were reviewed to determine if resident gender was associated with different types and frequency of incident reports. The most comment complaint about men physicians involved a medical error, while the most common complaint type about women included a communication-related event. Additionally, women were more frequently identified by name only, without a title such as “doctor”.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

Stressful situations can degrade communication, teamwork and decision making. This commentary describes a program to minimize the potential impact of implicit biases in a crisis. Steps in the process include Pausing to Listen, working to Ally and Collaborate, and seeking to Empower patients and staff members.

Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.

… on this relationship is warranted. … Casalino LP, Li J, Peterson LE, et al. Relationship between physician burnout …

By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

… J Am Med Inform Assoc … Problem lists , while an important … which needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to improve problem list documentation. J Am Med Inform Assoc. Epub 2021 Dec 28. …

… successfully leveraged during the COVID-19 pandemic . … Phillips RA, Schwartz RL, Sostman HD, et al. Development and …

Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice. 

… Am J Med Qual … Encouraging adverse event reporting among … to promote patient safety event reporting by trainees. Am J Med Qual. doi: 10.1097/01.JMQ.0000749848.73584.ac. …

Reducing resident shift duration can improve resident health and patient safety. This study found that resident shifts limited to 16 hours can reduce performance impairment and medical errors, compared to extended work shifts (24+hours).

In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.