Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight. Findings indicate that patients who spent an overnight in the ED had a higher in-hospital mortality rate, increased risk of adverse events, and longer length of stay; this risk was exacerbated for patients with limited functional status.

Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.

Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.

Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.

Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.

True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.

The surgical time out is an effective strategy to reduce errors and improve team communication but full team participation remains a challenge. This article describes a Plan, Do, Study, Act project of developing and implementing a white board time out checklist to encourage all operating room personnel to participate. A significant increase in the number of completed time out items was seen after implementation.

The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.

A study conducted in 2011 concluded that pharmacy students identified more prescribing errors than their medical or nursing counterparts. This study replicates the 2011 study with first- and second-year physician assistant (PA) students. The results suggest PA students, regardless of year, identified prescribing errors at similar rates to medical and nursing students, although identification rates were low for all three student groups.

Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.

The quality improvement and patient safety (QIPS) curriculum is increasingly being added to resident education, but implementation and quality of these programs varies. In this study, continuous improvement specialists (CIS) were embedded in resident teams to create an A3, a quality improvement tool. A key component to the QIPS curriculum was aligning resident projects with quality improvement efforts already underway in the department.

Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.

Patient safety can be improved when all staff feel empowered to speak up about errors. In this systematic review, the authors identified 11 studies on the effectiveness of trainings to increase nurses' assertiveness to report medical errors. Interventions resulted in significant improvement in nurses' speaking up behavior, but not their attitude or confidence after training. Structured content, use of multiple teaching approaches, and adequate training time were critical to significant improvement.

Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.

Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.