Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.

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.

System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.

Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.

Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.

… Obstet Gynecol … Effective apology for medical mistakes is a cornerstone for healing and improvement. This piece … play in protecting clinicians who err and apologize in a court of law. …

Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.

Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.

Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.

… BMJ Medicine … Pharmacists play a critical role in medication safety . This article evaluated the impact of a pharmacist-led information technology intervention ( PINCER ) among a retrospective cohort of 56.8 million National Health …

Radiologic diagnostic errors can result in delayed or unnecessary treatment. This paper describes five types of cognitive biases, with accompanying case study and images, that result in misdiagnosis. Both individual education and system-level solutions are described.

… This article describes the development and testing of a novel Quality Improvement Classification System (QICS) … medical and surgical specialties in order to capture a broader range of outcomes related to patient care, …

Debriefing after clinical events is an important opportunity for critical learning, process improvement, and enhancing team communication. This systematic review of 21 studies synthesized findings regarding the attributes and evidence supporting the use of clinical debriefing tools. While all of the evaluated tools included points related to education and evaluation, few tools included a process for implementing change or addressed staff emotions. The authors include recommendations for clinicians, educators and researchers for teaching, implementing and evaluating clinical debriefing tools.

… BJPsych Open … Families can offer a unique perspective to improve patient care. This study …

… in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency …

… … Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous … by diagnostic safety experts and stakeholders. … Zwaan L, Smith KM, Giardina TD, et al. Patient generated research … exercise. Patient Educ Couns. 2023;110:107650. 10.1016/j.pec.2023.107650 …