When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.

Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).

Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.

… administration errors . … Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error …

Nurses’ willingness to speak up about resident safety concerns varies based on anticipated leadership response and support. Clinical and non-clinical staff at six Department of Veterans Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand the association between resident safety and safety climate. Staff at high safety climate facilities described open communication and leadership responsiveness as contributors to a strong safety climate and willingness to speak up.

Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

… in improving infant sleep environments. … Batra EK,  Lewis M, Saravana D, et al. Improving hospital infant safe …

Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.

The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.

Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.

This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 

Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.

… and employed debiasing strategies . … Gupta A, Quinn M, Saint S, et al. How physicians think: a case-based …

This cross-sectional study examined the impact of safety climate on adverse events occurring in Veterans Administration (VA) nursing homes and community living centers. Survey results suggest that nursing homes may reduce adverse events by increasing supportive supervision and a safer physical environment. The survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls and catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls, and catheter use.

This study describes the results of surveillance for COVID-19 among residents and staff of an independent/assisted living community in Seattle, Washington. Residents and staff were tested for COVID-19 and completed a symptom questionnaire assessing systems for the preceding 14 days; residents (but not staff) were retested 7 days later. COVID-19 was detected in 3.8% of residents and 3.2% of staff; none of the residents reported significant symptoms but the staff were symptomatic. After 7 days, resident testing was repeated and one new asymptomatic infection was detected. This study highlights the challenges of detecting COVID-19 in asymptomatic persons and the importance of early surveillance and prevention strategies in reducing virus transmission in assisted living communities.

Simulation is an active learning methodology being used in hospitals to improve patient care.  Results of this systematic review that focused on acute care nurse simulation training and patient safety outcomes indicate that simulation training can be effective for improving patient safety outcomes in this context; the authors note, however, that additional high–quality research is needed to support this field.

Disruptive and unprofessional behavior is a well-described problem in health care. In this study of nurses working in both the inpatient and outpatient oncology setting at a single health care institution, researchers found a positive association between emotional, physical, verbal, and defiant behaviors—referred to as horizontal violence—and workplace bullying. They conclude that establishing a positive workplace culture is essential for mitigating workplace violence.