Previous analyses have found that orthopedic surgery is one common source of patient harm. This survey of 305 orthopedists found that involvement in a medical malpractice lawsuit within the past two years increased the likelihood of experiencing burnout and reporting a medical error resulting in patient harm in the past year.

Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.

Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Healthcare-associated infections (HAIs) continue to be a preventable safety problem. This study explored the correlation between hospitals’ Leapfrog Hospital Safety Grade and Magnet designation on measures of patient safety, including healthcare-acquired infections (HAIs). The researchers found that Leapfrog safety scores were higher for Magnet-designated versus non-Magnet-designated hospitals – particularly for structural measures – but Magnet-designated hospitals did not have lower HAI rates.

Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.

Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.

Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.

The effectiveness of incident reporting systems is hindered by underreporting. This cohort study describes the characteristics of incident reports submitted by trainees in a large academic medical center. From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing unprofessional interactions. Findings suggest that awareness and support for the online incident reporting system among trainees was high.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

Delayed diagnosis of infectious diseases can lead to serious patient harm. This survey of over 500 infectious disease clinicians revealed that diagnostic delay often involved diagnoses of infective endocarditis and epidural abscesses. Respondents identified several factors contributing to diagnostic delays including usual clinical presentations and the timing of infectious disease consultations.

Prescribing antibiotics increases the risk of resistant infections and can lead to patient harm. From December 2019 to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use Program. The goal of the intervention was to support implementation and sustainment of antibiotic stewardship into practice culture, communication, and decision-making. Practices that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute respiratory infections at program completion in November 2020.

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.

… J Healthc Manag. 2022;67(3):192-205. doi: 10.1097/jhm-d-21-00208 …

Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

The complexities of the care environment are known contributors to harm and initiative failure. The authors suggest that systemic versus siloed approaches to patient harm reduction will reduce difficulty in accomplishing improvement.