The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.

Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.

… J Am Med Inform Assoc … Although e-prescribing has improved …

Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

Health profession schools are increasingly using interprofessional simulation-based education (IP-SBE) for learners to understand each other’s roles in team-based care. Learners’ ability to feel psychologically safe during IP-SBE is necessary for full learner participation. This scoping review analyzed 27 studies of psychological safety within IP-SBE. Learners were more likely to feel safe in well-designed simulations with facilitators who are experienced in pre- and de-briefing. Barriers to psychological safety included hierarchy, being observed, uncertainty, and poorly designed and delivered simulations.

The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED discharge were analyzed to determine if the deaths were anticipated or unanticipated and/or due to medical error. Rates of unanticipated death due to medical error were low, however clinicians should consider related patient, provider, and system factors.

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

… J Patient Saf … Using data from the Veterans Health … communication and coordination of care. … Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse … veteran population in the Veterans Health Administration. J Patient Saf. Epub 2021 Aug 19. …

Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.

Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 

… J Eval Clin Pract … Many organizations have implemented … interventions. … Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: Health … designed to help them prepare for coping with error. J Eval Clin Pract. Epub 2021 Mar 6. doi: 10.1111/jep.13555. …

… Jt Comm J Qual Patient Saf … Prior research has identified racial … among health care workers and leadership.   … Austin JM, Weeks K, Pronovost PJ. Health system leaders' role in … to prioritize eliminating health care disparities. Jt Comm J Qual Patient Saf. Epub 2020 Dec 20.     …

The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  

… J Patient Saf. … The goal of high-reliability organizations … 18 additional VHA sites. … Sculli  GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for …