Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.

Electronic health records (EHR) house and provide access to a plethora of data to inform care and management decisions. This commentary suggests that EHRs have yet to be fully embraced as a tool to proactively identify areas of risk that could lead to legal action.

People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

… visitation, both during the pandemic and beyond. … Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable …

… safety, and continuous analysis of errors. … Adelman JS, Gandhi TK. COVID-19 and patient safety: time to tap into our …

The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

… may incentive efforts to reduce nursing staff turnover. … Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). …

This Viewpoint presents examples of short-term positive effects resulting from early COVID-19-related patient safety efforts, including a focus on (1) high-reliability organizations and safety culture focusing on transparency, collaboration, reporting, and speaking up, (2) prioritizing workplace safety, and (3) removing barriers to using health IT (e.g., EHRs, telemedicine) to improve safety and how to create some permanent/sustainable methods to prevent harm.

The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.

Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.

… , and (4) patient engagement and codesign of healthcare. … Gandhi TK, Feeley D, Schummers D. Zero harm in health care …

… & safety … BMJ Qual Saf … Over the last decade, the Lucian Leape Institute has explored five key areas in health care to … training programs. In a past PSNet interview , Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a …

The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.