A study conducted in 2011 concluded that pharmacy students identified more prescribing errors than their medical or nursing counterparts. This study replicates the 2011 study with first- and second-year physician assistant (PA) students. The results suggest PA students, regardless of year, identified prescribing errors at similar rates to medical and nursing students, although identification rates were low for all three student groups.

Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.

Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.

Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.

Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.

Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This report compiles reports submitted in 2022 and compares results to previous years. There was a decrease in the total number of reports submitted, but serious and high harm events increased. The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed by Complication of Procedure/Treatment/Test, Medication Error, and Fall.

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.

Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.

… as a common distractor.  … Nasri BN, Mitchell JD, Jackson C, et al. Distractions in the operating room: a survey of the …

Healthcare-associated infections (HAIs) are among the most common complications of hospital or long-term care stays. HAI data reported to the Veterans Affairs centralized database was analyzed to determine rates of several HAIs, both before and during the pandemic, to assess changes. Rates were variable in acute care and no changes were seen in long-term care.

Healthcare providers may decide to speak up or remain silent about patient safety concerns based on the expected response of the recipient. In this study, clinicians from multiple disciplines responded to two hypothetical speaking up scenarios to explore the impact of communication behavior and speaker characteristics (e.g., discipline, seniority, presence of others) on the recipient’s intended response. Each of the factors played a role in how the clinician received the message and how they would respond.

Reporting adverse events and lessons learned can help improve patient safety beyond the original impacted facility, but low-quality reports can hinder learning. This study describes the quality of reports submitted during the first three years of England’s mandatory Learning from Deaths (LfD) program. While up to half of National Health Service (NHS) hospital trusts submitted data for all six regulatory statutes, a small minority did not submit any data. Three years in, the identification, reporting, and investigation of deaths has improved, but evidence of improved patient safety is still lacking.

In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.

Physical and verbal violence against healthcare workers has been identified as a sentinel event by the Joint Commission. In this secondary analysis of survey data on workplace violence (WPV), researchers explored which attributes of patient safety culture may predict healthcare workers’ experiences of WPV and burnout. Better teamwork and staffing were among the attributes associated with lower risk of WPV.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Blood transfusions errors can have serious consequences. In this retrospective study including 15 community hospitals, researchers identified high rates of unnecessary blood transfusions, primarily attributed to overreliance on laboratory transfusion criteria and failure to follow guidelines regarding blood management.

… be successful with nursing staff. … Baldwin CA, Hanrahan K, Edmonds SW, et al. Implementation of peer messengers to …

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.

In response to concerns about workplace violence (WPV) directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations to increase organizational awareness of this risk. This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ burnout and patient safety. As anticipated, WPV increased nurse burnout, but unexpectedly, a strong WPV-reporting culture also increased the negative effect of WPV on burnout.