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.

Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.

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 and caregiver engagement in medical treatment can promote safety. This scoping review explored the qualitive research regarding how patients and caregivers engage in safety during cancer treatment. Four themes were identified – patient perception and involvement in safety; patient engagement in their care; safety as a collective responsibility; and the importance of caregivers relative to the amount of support they receive.

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.  

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 …

… as cultural competence during implementation. … Joseph K, Newman B, Manias E, et al. Engaging with ethnic minority …

Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.

… to children without intellectual disabilities. … Mimmo L, Harrison R, Travaglia J, et al. Inequities in quality and …

Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.

… especially for nurses. … Lamming L, Montague J, Crosswaite K, et al. Fidelity and the impact of patient safety huddles …

… to alert practitioners to concerns). … Newman B, Joseph K, Chauhan A, et al. Do patient engagement interventions work …

Prior research found that patients with learning disabilities (e.g., autism, attention deficit disorder, Down’s syndrome) face numerous patient safety threats. In this narrative review, the authors synthesized academic and grey literature exploring patient safety outcomes for individuals with learning disabilities in acute care settings. Findings suggest that individuals with learning disabilities experience poorer patient outcomes but that increasing family and caregiver engagement as well as provider understanding of the needs of people with learning disabilities can improve outcomes.

… alongside individual-level interventions. … Janes G, Harrison R, Johnson J, et al. Multiple meanings of …

The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  

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.

… 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.

This qualitative study compared four high-performing geriatric inpatient units with four average-performance units in order to understand factors that contribute to high performance. The authors conclude that the safety practices did not differ between the high versus average performers. Instead, optimal teamwork and positive safety culture led the high-performing wards to implement these safety practices in a more effective way.