This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.

The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.

Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

… of costs per 1,000 patient days. … Dykes PC,  Curtin-Bowen M, Lipsitz S, et al. Cost of inpatient falls and cost-benefit …

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

Disinfection and cleaning of the hospital environment can promote a reduction in healthcare-associated infections. This commentary discussed the important, yet largely invisible, role of the hospital cleaning workforce. The authors also describe additional benefits provided by cleaners, such as reducing patient isolation and alerting clinical staff to patient changes.

When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.

Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

Advanced technology – such as radiofrequency identification (RFID), sensors, or mobile apps – is increasingly used to improve patient safety. This study explored whether the use of “internet of things” (i.e., network of physical objects – “things” – that are embedded with sensors, software or other technology to connect and exchange data with other devices, such as RFID technology) is effective at reducing patient falls and improving hand-hygiene compliance.

Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.

Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.

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.

This systematic review evaluated the impact of providing patients with access to electronic health records (EHR) on measures of quality of care (i.e., patient-centeredness, effectiveness, efficiency, timeliness, equity, and safety). Meta-analysis found that sharing EHRs with patients is effective in reducing HbA1c levels; the included studies generally found positive effects on patient-centeredness, health outcomes, and adherence to preventative services. However, the authors concluded that more methodologically robust studies are necessary to quantitatively assess the impact of sharing EHRs with patients.  

Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.

… risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed …

Artificial intelligence may have the potential to improve patient safety by enhancing diagnostic capability. In this study, researchers applied machine learning techniques to a large amount of pediatric electronic health record data and found that their model was able to achieve diagnostic accuracy analogous to that of skilled pediatricians.

… programs and future directions for the field. A past WebM&M commentary described the harms associated with …