Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.

A culture of safety is foundational to successful patient safety initiatives. This systematic review explored the relationship between safety climate and safety-related behaviors across various industries, including healthcare.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.

Potentially inappropriate medications (PIMs) are common among older adults living in residential care facilities. This study examined the impact of the Australian Residential Medication Management Review (RMMR) service (a patient-centered medication review program) on PIM prescribing among older women living in residential aged care facilities. Researchers identified no evidence of an association between the medication review program and use of PIMs in the following year.

Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic error played a part in rapid response team activations or unplanned admissions to the intensive care unit. Clinicians reported that 18% of acute care patients experienced diagnostic errors.

Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.

Patients are increasingly using the internet and conversational agents (CAs) like Siri, Alexa, and Google to find answers to their healthcare questions. Investigators used these CAs to detect errors and failures in calculating correct insulin doses. Failure classes include misunderstanding and misrecognition of words. Potential failures must be considered before deployment of CAs in safety-critical environments.

This article reports on the impact of an OB hospitalist program on serious safety events in one hospital over a two-year period. After program implementation, there was a significant reduction in serious safety events.

Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This retrospective case-control study of inpatients being administered at least one opioid dose sought to identify risk factors predisposing inpatients to opioid-related adverse drug events (ADEs) requiring the use of naloxone. Patients 65 years of age or older, female, receiving orthopedic surgery, certain comorbid conditions, or receiving patient-controlled analgesia were more likely to require naloxone.

Underreporting of adverse drug reactions (ADRs) is an international patient safety problem. This systematic review of studies assessed how various strategies designed to improve ADR reporting impacted ADR rates. While all strategies increased ADR reporting, particularly those using electronic reporting tools, the quality of the studies was generally low. The authors expressed the need for higher quality studies to focus on how electronic methods might improve ADR reporting.

Patient safety in the home has not been well defined and there have been few studies of this setting. This study examines the concept of patient safety in the home and identifies personal health information management tools to support and maximize patient safety in the home. The study findings demonstrate the physical, emotional, social and functional dimensions of patient safety in the home and ways for informatics tools to maximize safety aspects.

Pharmacist oversight of medication prescribing is an established safety strategy. This review explores the impact of pharmacists on reducing inappropriate polypharmacy in aged care facilities and the cost-effectiveness of this risk management strategy to substantiate the value of the practice.

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

… quality and safety than mortality. A prior AHRQ WebM&M commentary explored the implications of the July effect …

Handoffs in the inpatient setting represent an ongoing challenge for patient safety. This intervention involving event reports for key overnight incidents automatically emailed to the daytime team reduced handoff duration, and team members suggested that this improved the quality of handoffs. This workflow-informed and technology-enabled approach reflects the growing influence of systems thinking in health care safety.

This commentary provides information about an approach to augment patient safety through public health engagement. Implemented in partnership with six African countries to spread and sustain safe care practices, the initiative utilized a seven-component model to bring together community leaders and hospitals to drive improvement. A recent AHRQ WebM&M perspective covered lessons learned throughout implementation of the program.