The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.

Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.

COVID-19 restrictions and patient safety concerns have greatly expanded the use of telehealth and virtual visits. Through patient satisfaction surveys and patient complaints, this US hospital evaluated the quality and safety of virtual visits in March and April of 2020. Five patient complaints were submitted during this timeframe and overall patient satisfaction remained high. Safety and quality risks were identified (e.g., diagnostic error) and best practices were established.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Patient falls are an ongoing source of preventable harm, yet mitigating the fall risk of inpatients remains challenging. Conducted across three academic medical centers, this study evaluated the impact of a fall-prevention toolkit (Fall Tailoring Interventions for Patient Safety (Fall TIPS)). The Fall TIPS toolkit supports nurses in providing tailored, fall-prevention intervention and engages patients and families in fall prevention efforts. After implementation of Fall TIPS toolkit, there was a 15% reduction in falls and a 35% reduction in falls with injuries.

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

This article describes the implementation of a new system for identifying, communicating, and resolving safety reports pertaining to COVID-19 in one academic tertiary care center through the use of electronic safety reporting systems and daily huddles.

This article describes the development of a COVID-19 exposure disclosure checklist which reflects five core competencies for effective disclosure conversations with patients and families. The authors discuss disclosure with persons who have limited English proficiency, undocumented and immigrant patients, and patients with specific health needs.

This article discusses the state of the evidence on apology laws and methodological limitations which may impair researchers’ ability to assess reductions in liability attributable to these laws. 

This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.

Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving the patient safety issue, but successful implementation has been challenging. This study used qualitative methods to explore factors supporting successful CRP implementation at two Massachusetts hospitals. Identified facilitators of successful implementation encompassed institutional leadership support including oversight by a full-time project manager, investments in physician training, positive relationships between hospital risk management and the liability insurer, use of formal decision protocols, collaborative group implementation, and small hospital size.

Radiological exams are often ordered but go unscheduled, which can delay diagnoses and lead to other medical errors. In this retrospective study at one academic institution, the clinical necessity of 700 unscheduled radiologic examination orders (100 from each of seven different radiographic modalities) was examined. Study results indicate that, except for CT, obstetric ultrasound and fluoroscopy radiologic tests, the majority of unscheduled orders are clinically necessary and that 7% of all radiologic examination orders remain unscheduled a month or more after the order was placed.

In 2014, the Agency for Healthcare Research and Quality (AHRQ) began funding Patient Safety Learning Laboratories (PSLL) which use collaborative approaches to incorporate digital health tools to improve patient safety.  This research paper discusses the experiences of 12 inpatient units at one large tertiary care center after implementation of a PSLL intended to engage patients, families and the care team in identifying, assessing and reducing threats to patient safety in real time through EHR integration.  

A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.

This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.

Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.

This retrospective review of nearly 900 incident reports related to diagnostic imaging found that the most common type of safety problem was linked to the imaging procedure. Events associated with communicating abnormal results were less common but had a higher potential to harm patients. Most events had multiple contributing factors.

Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

Human factors engineering is being increasingly used in the design of patient safety interventions, particularly with regard to health information technology. This qualitative study examined the use of human factors and systems engineering principles within an AHRQ-funded Patient Safety Learning Laboratory that focused on implementing digital health tools to improve safety. Surveys and focus groups provided insight as to the utility of specific human factors techniques for optimizing health information technology–based interventions.