Health care-associated infections continue to be one of the most common health care-related complications. This systematic review including 67 studies identified several cost-effective interventions addressing health care-associated infections, including screening high-risk individuals, universal decolonization in intensive care units, hand hygiene, environmental cleaning, and surveillance. The authors found limited evidence evaluating the cost-effectiveness of other strategies such as education and training or use of personal protective equipment.

Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).

… points and 30 significant failure points. … Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the …

Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.

Quality improvement and patient safety (QIPS) training is increasingly being incorporated into formal medical education. This article describes an integrated framework for QIPS training for internal medicine residents focused on four areas: (1) culture of safety, (2) strategies for investigating events and tracking improvements, (3) reporting and presenting events, and (4) improvement work. This specialty-agnostic framework allows for integration across graduate medical education (GME) specialties and can serve as a model for other institutions.  

The COVID-19 pandemic has led to patients delaying or forgoing necessary health care, which can contribute to diagnostic and treatment delays.  This retrospective cohort study used primary care data to investigate the indirect effect of the COVID-19 pandemic on primary care health care use and subsequent diagnoses among residents in a poor, urban area in the United Kingdom. Between March and May 2020, there was a 50% reduction in expected diagnoses for mental health conditions, as well as substantial decreases in diagnoses and associated medication prescriptions for circulatory system diseases and type 2 diabetes.  

The coronavirus pandemic has disrupted patient care seeking behaviors. This article discusses this phenomenon and its impact on the timing of diagnosis due to fear of contracting COVID-19 or threats resulting from the economic shutdown implemented to reduce spread of the virus.

Simulation has been adopted as a valuable teaching tool in health care. In this study, researchers used relational dialectic theory and simulation to better understand the impact of interprofessional communication challenges on both team-based and individual disclosure of error.

Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.

Numerous factors affect whether providers disclose medical errors to patients. In this study, researchers describe the development and validation of a tool to identify barriers to error disclosure.

Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health care. Discussing weaknesses associated with using RCAs, this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis quality, and insufficient feedback should be addressed to enhance the effectiveness of RCAs and sustain organizational learning from failure.

Junior doctors at a British hospital reported a willingness to help improve safety by reporting concerns, but described several barriers to doing so. These included an overall lack of a culture of safety, a cumbersome reporting process, and insufficient role modeling by more senior physicians.