Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Algorithms are commonly used to guide clinical decision-making, but concerns have been raised regarding bias due to the use of race-based data. This qualitative analysis examined perspectives of 42 stakeholders (e.g., individuals, representatives from clinical professional societies or payers, etc.) regarding the use of race- and ethnicity-based algorithms in healthcare. Seven themes were identified, highlighting concerns regarding bias, algorithm transparency, lack of standardization regarding how race and social determinants are collected and defined, and the use of a social construct as a proxy in clinical decision-making.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.

Incident reporting systems are common tools to detect patient safety hazards. This systematic review synthesized evidence from 41 studies using incident reporting system data to identify and characterize critical incidents. Medication-related incidents and incidents due to “active failures” were the most commonly reported events. The authors observe that only one in three studies reported on corrective actions due to the incidents, highlighting the need to emphasize the importance of learning from errors.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    

This observational study enrolled 2,576 women undergoing cesarean delivery at a single tertiary care hospital over a five-year period to evaluate the impact of an evidence-based bundle on surgical site infections. The comprehensive and multidisciplinary bundle included preoperative, intraoperative and postoperative actions. Implementation of the bundle resulted in a 60% reduction in the risk of surgical site infections, from 1.5% in the preintervention period to 0.56% after implementation.

Using medical residency as an example, this paper explores gender disparities in evaluations as individuals transition roles from student to health care professional and whether differences in resident performance (rather than differences in perceptions of performance) contribute to gender disparities in evaluations. The authors found that men and women are reviewed as equally capable at the beginning of residency, but by year three after roles shift from ‘student’ to ‘colleague’, men are perceived as outperforming women. When comparing feedback on medical errors, women receive more harsh criticism and less supportive feedback than men by year three of residency.

Heparin – a commonly used anticoagulant – is a high-risk medication and a patient safety risk to both adults and children. This study used a failure mode and effects analysis (FMEA) to prospectively analyze various steps in the preparation, use and disposal of heparin in a pediatric hospital to identify areas of improvement. The FMEA identified 233 potential failures and 737 potential causes of failure. Underlying causes of failure included mathematical errors, EHR challenges, and varying practice and operating procedures (or lack thereof). Countermeasures to address underlying causes are also addressed.

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

This pre–post study sought to examine whether a task force could reduce the risk of unprofessional behaviors at an acute care center. Certain types of negative behaviors declined, but the authors suggest that additional strategies are needed to enhance safety through professionalism.

Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.

The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.