Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.

Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Electronic health records increase safety in many ways but are not without problems. In this survey, emergency department nurses reported that electronic health record (EHR) issues (downtime, workflow) negatively impacted patient safety such as documentation or orders placed on the wrong patient chart.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

Extended and overnight shifts are associated with higher adverse event rates and burnout. This mini review summarizes the impact of overnight shifts on nurses' health, patient and public safety, and organizational costs (e.g., those related to nurse turnover). Organizational strategies to promote nurses' health and reduce errors are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift to high-cost measures such as referral to sleep specialists or paid transportation home.

Previous research has identified gaps in medication reconciliation practices among hospitalized children. This quality improvement found that increased utilization of a patient-friendly discharge medication platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge medication reconciliation in pediatric acute care patients.

The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.

Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.

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 Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

… educational interventions. … Riesenber LA,  LA, Davis R, Heng A, et al. Anesthesiology patient handoff education …

Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.

Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.

Patient perspectives can provide unique insights into care quality. This commentary examines how ascertaining whether patients ‘feel safe’ results in their ‘being safe’ is an ineffective goal in patient safety. The authors argue that patient experiences degrading humanity be considered never events and suggest feelings as important considerations for patient engagement and health care improvement.

Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.  

The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.

Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.