The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.

Risk reduction in home health faces unique challenges. In this study of registered nurses providing home health, challenges included finding a balance between the patient's autonomy and ensuring a safe environment, building relationships with the patient and family, and gaps between resources and requirements.

Intensive care units (ICU) experienced extensive, rapid reorganization at the beginning of the COVID-19 pandemic. This qualitative study of ICU personnel uncovered multiple ways they experienced decreases in patient safety during the initial reorganization. They reported the unfortunate necessity of "cutting safety corners," poorly adapted temporary ICUs, and feelings of increased personal responsibility due to changes in skill mix. Participants reported the care provided was safe, but of lower quality than was typical.

Remote patient monitoring (RPM) allows patients to remain in their homes while still receiving disease management. This study involved patients with chronic conditions who were receiving RPM and clinicians (nurses and physicians) who were providing RPM. Clinicians described the importance of knowing patients' level of health literacy and ensuring they understand when someone is reviewing their remote data (e.g., not on weekends). Patients reported feeling more confident, knowing someone was checking on them weekly. Overall, both groups had positive perceptions of patient safety.

Providing in-home care for home-dwelling adults presents unique patient safety challenges. This qualitative study with 13 registered nurses in Sweden explored how nurses ensure safe home health care among home-dwelling older patients. Findings highlight the importance of continuity of care, trust between patients, caregivers, and nurses, and adapting safety requirements to meet environmental conditions and maintain a sense of home.

Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.

Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.

Diagnostic error and misdiagnosis of stroke patients can lead to preventable adverse events, such as treatment delays and adverse outcomes. Researchers at a Swiss hospital retrospective reviewed patients admitted for transient ischemic attack (TIA) or ischemic stroke and found that a trigger tool could accurately identify preventable events among patients with adverse events and no-harm incidents. The most common preventable events were medication events, pressure injuries, and healthcare-associated infections.

… erroneous, or incomplete nursing care and treatment. … Lindblad M, Unbeck M, Nilsson L, et al. Identifying no-harm incidents in home …

Patient engagement in safety is considered a best practice and a National Patient Safety Goal, but less is known about patients' perceptions regarding this topic. In this survey study involving 1445 patients in Sweden, researchers found that more than 80% of respondents felt comfortable directing questions to doctors and nurses. Patients who had filed a formal complaint reporting a safety concern were found to believe with greater certainty that the patient perspective can improve the safety of care.

In this study, researchers used trigger tools to identify adverse events among patients receiving home health care. They found that adverse events occurred frequently, were mostly preventable, and often led to patient harm in the form of extra health care resource utilization.

This qualitative study examines nurses' perspectives regarding patient engagement. Nurses reported that they believe health care workers and patients share responsibility for patient participation in care. Participants identified barriers to patient engagement, including time limitations, insufficient continuity with other providers, and lack of trust.

This study describes the development and validation of a trigger tool to identify possible adverse events among patients receiving home health care. The final result of 38 triggers with an overall positive predictive value of 41% suggests that this approach may be valid, if time-intensive, for safety work in home health care.

Hospitals employ various methods to detect adverse events, each with their own advantages and drawbacks. In this study at an academic medical center, the Global Trigger Tool identified an adverse event rate of 20%, and only 6% of these cases were submitted to the voluntary reporting system.

Prior studies have found that the Global Trigger Tool has relatively poor interrater reliability for identifying adverse events. This qualitative study explored how teams of reviewers adapted the tool over time to increase reliability and utility of the tool.

This comparison of two different methodologies for retrospectively detecting safety events found that the methodology used in the Harvard Medical Practice Study was more accurate than that used in the Global Trigger Tool.

This study found that the Global Trigger Tool had poor inter-rater reliability for both detecting adverse events and determining the severity of such events. These findings contradict the results of a prior study.

This study used multiple methods of error detection to determine the incidence of adverse events in patients discharged from an orthopedics department.