Patient safety is a global health concern. For this study, representatives from 27 countries reported on rules, laws, and policies in their country related to adverse events and medical errors. As expected, laws varied widely between countries regarding issues such as apology laws, patient compensation schemes, and legal and emotional support for clinicians involved in adverse events.

Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.

Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.

… J Patient Saf … While prior research has shown patients want … to disclose errors and apologize. … Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is …

Medication administration errors made by parent or caregivers can result in medication errors at home. This systematic review found that 30% to 80% of pediatric patients experience a medication error at home, and that the risk increases based on characteristics of the caregiver and if a prescription contains more than two drugs.

Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.

Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.

… Int J Health Care Qual … Online courses enable employees to …

Retained foreign objects are a persistent never event. This commentary describes how one organization reduced the occurrence of this surgical complication. Needs assessments, multidisciplinary engagement, risk classification, and modeling approaches were employed to inform the initiative. These activities helped to design training efforts to enhance awareness of the problem.

Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.

This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.

… Journal of Medical Internet Research … J Med Internet Res … Investigators implemented a website in a …

Health information technology has the potential to facilitate patient safety tasks. This study described the development of a mobile health application for patient safety managers to enable activities such as tracking of risk management processes and safety audits. Users who tested the application reported high satisfaction with the tool, though its efficacy in enhancing safety was not studied.

This qualitative study examined perceptions of nurse and physician quality management leaders about what clinicians experience after being involved in adverse events. Participants acknowledged the emotional impact of adverse events on clinicians and the need for formal mechanisms to offer support to second victims.

This survey of health care organizations found that most reported having inadequate support for second victims. Many organizations lacked protocols for responding to serious adverse events, especially in primary care. These results underscore the importance of implementing safety initiatives to address health care providers' needs following adverse events.

This survey conducted at four hospitals in Spain found that patients' perceptions of safety were strongly correlated with their overall perception of the hospital's reputation.

This survey of older adults who were taking more than five prescription medications daily found a strong association between poor physician–patient communication and an increased risk of patient-reported medication errors.

… the International Society for Quality in Health Care … Int J Qual Health Care … This study demonstrated that the number …

This cross-sectional study conducted in 58 hospitals in 5 Latin American countries found an overall point prevalence of adverse events of 10.5%, comparable to the frequency reported in other studies.