Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Health information technology (HIT) has improved many aspects of patient safety, but poor design can result in patient harm. This commentary describes how context influences vendor, organization, and user understanding of HIT-related errors and proposes system-level solutions, in particular a focus on user-centered design.

Incivility hinders clinical performance, increases errors, and negatively impacts safety culture. This review examines recent literature on the effects of incivility in healthcare and strategies to address it. The article proposes ways to implement those strategies, with an emphasis on the UK National Health Service. The authors conclude that tackling incivility begins with highlighting the issue organizationally, regionally, and nationally; ensuring robust reporting and recognition strategies; and, devising mechanisms to confront incivility.

Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

… cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events. …

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

… malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic …

Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.

Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.

People taking medications at home may have difficulty opening packaging which can result in improper, dangerous storage practices. This review includes 12 studies where participants were observed opening a variety of medication packages (e.g., blister packs, child-resistant containers). While all studies reported participant difficulty, no consistent contributory factors were identified, and the methodological quality of all studies was typically low. Additional research is required to encourage improvement in medication packaging.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

… to detract from the safe use of artificial intelligence. … Sujan M, Pool R, Salmon P. Eight human factors and ergonomics principles for …

Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

Emergency surgery carries an increased risk of death compared to elective surgery. This study used a regional electronic health record (EHR) to examine clinical risk factors associated with mortality in emergency general surgery. Risk factors for both inpatient and 1-year mortality included older age, underweight, neutropenia, and elevated lactate.

Digital health tools are increasingly used across all areas of the healthcare system. In this study, researchers convened an interdisciplinary expert panel to identify patient safety concerns associated with emerging digital health technologies and to outline recommendations to address these concerns.