I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.

Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.

… communication are discussed. … Douglas RN, Stephens LS, Posner KL, et al. Communication failures contributing to …

Physicians may be faced with difficult decisions regarding potential limits to patient access to care during the COVID-19 pandemic in order to preserve resources to meet the medical needs of patients diagnosed with COVID-19. This article describes a scoring system incorporating resource limitations and COVID-19 transmission risk to facilitate decision-making and triage for medically-necessary, time-sensitive procedures while balancing patient risk and public health concerns.

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Interruptions and distractions are well-recognized sources of error. Distractions in the operating room are common. In this randomized crossover study, researchers observed residents performing a virtual salpingectomy and subjected them to time periods in which they received pages versus quiet phases without interruptions. The majority of residents made at least one unsafe clinical decision while trying to multitask, further supporting that interruptions and distractions adversely impact patient safety.

… Comm J Qual Patient Saf … Incident reporting systems are a popular method for hospitals to detect patient safety … , but their effectiveness is unclear. This study describes a taxonomy for organizing and prioritizing safety hazards …

First-year residents who were allowed to nap for 20 minutes at midday had improved cognitive performance and fewer attentional failures than residents who did not nap. However, the study did not control for potential confounders, such as residents' caffeine intake.

Formal teaching of error disclosure techniques improved obstetrics and gynecology residents' ability to fully disclose adverse events.

… , emergency medicine , and obstetrics . This study uses a previously described database to compare liability profiles … damage claims decreased in recent years (though still a leading cause), maternal nerve injury and back pain …

… American Surgical Association … Disruptive behaviors are a growing concern in patient safety and system-level solutions remain a challenge. This study adds to those concerns by finding …

This report reviews potential fire sources, provides guidelines to prevent and reduce harm from operating room fires, and describes fire response protocols.

… used simulated resuscitation scenarios and found that a confusing user interface limited paramedics' ability to properly use two common defibrillator models. A related editorial discusses the challenge of uniting … patient safety principles and usability. … Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Usability study of …

The authors describe their institution's Patient Safety Alert system in which employees are required to stop activity and report situations that they believe may cause patient harm.

This retrospective analysis of 460 malpractice claims describes the types of events that contributed to unsafe care. The surgeon-reviewers identify several problems in the categories of diagnosis and treatment that occurred more frequently in the preoperative and postoperative periods than intraoperatively. The reviewers also rate the surgical care quality and whether the complications leading to the suit were preventable. The American College of Surgeons intends to use these findings to promote educational efforts and patient safety awareness around the identified areas for improvement. Anesthesia and obstetrics and gynecology have also used closed claim reviews to identify opportunities for error prevention.