Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

… rather than on errors or what goes wrong (Safety-I). This article describes the development, implementation, … successful quality improvement initiatives. … Loving VA, Nolan C, Bessel M. An asset-based quality improvement tool …

People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

… safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver … visitation, both during the pandemic and beyond. … Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable …

Efforts to improve diagnosis recognize the value in patient-centered care. This commentary outlines how a diagnostician can enfold patient centeredness into their practice, which includes the seeking of knowledge and moderation of actions taken to arrive at a diagnosis. This piece is part of a series on diagnostic excellence.

… implementation to reduce implicit bias. … Vo JB,  Gillman A, Mitchell K, Nolan TS. Health disparities: impact of health disparities …

Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.

Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.

At the start of the COVID-19 pandemic, many elective surgical procedures were canceled or postponed due to limited resources (e.g., personal protective equipment, diagnostic tests, redeployment of healthcare personnel). This commentary discusses the implications of rationed non-urgent surgical care within the context of medical ethics: beneficence, non-maleficence, justice, and autonomy. The authors developed an algorithm to guide surgical teams through the decision-making process of delaying non-urgent surgical procedures, if necessary, in the future. 

The full impact of the COVID-19 pandemic on patient safety in the healthcare system is still unknown. New patient safety concerns have been introduced, and existing concerns have been exacerbated. The authors suggest several high reliability strategies to prevent and learn from patient safety hazards, including transparency, a culture of safety, and continuous analysis of errors.

The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

… may incentive efforts to reduce nursing staff turnover. … Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). …

… early COVID-19-related patient safety efforts, including a focus on (1) high-reliability organizations and safety … methods to prevent harm. … Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30(2):141-145. …

… J Qual Health Care … The authors of this editorial propose a five-step strategy for patient safety and quality … the learning system to develop resilience . … Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality …

The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.