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.

Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

… J Gen Intern Med … COVID-19 ushered in new diagnostic … in hospitalized patients under investigation for COVID-19. J Gen Intern Med. Epub 2023 Mar 23.  …

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.

… be considered in future interventions. … Cresham Fox S,  Taylor N, Marufu TC, et al. Paediatric family activated … review. Intensive Crit Care Nurs. 2022:103363. 10.1016/j.iccn.2022.103363 …

… Programme Grants Appl Res … Electronic prescribing (e-prescribing) is an established medication error reduction … in e-prescribing system decision making. … Sheikh A, Coleman J, Chuter A, et al.  Programme Grants Appl Res.  2022;10(7): …

Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

… non-preventable deaths (17%). … Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR …

… J Hosp Med … I-PASS is a structured handoff tool to enhance … adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across … prospective effectiveness implementation study. J Hosp Med . Epub 2022 Nov 3. doi: 10.1002/jhm.12979 …

Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.

Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements. 

… or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest … respiratory conditions or pain. … Patterson ME,  Bollinger S, Coleman C, et al. Medication discrepancy rates and sources …