The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.

Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.

Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.

This article discusses several aspects essential to surge planning and preparing for the COVID-19 pandemic, including surge planning, limiting health care worker exposure, logistics for medication delivery, delivering emergent care in patients with COVID-19, and safe practices for patient transport.

Transitions of care happen multiple times in a patient’s hospital stay and are common times for preventable errors. This study evaluated the impact of errors in the emergency department management of pediatric patients who were admitted and then transferred to the pediatric ICU (PICU) within 12 hours of admission.  PICU transfers after an ED management error had significantly shorter floor length of stay, longer PICU stays, and received more interventions.

This pre–post study found that implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, infections, unplanned return surgeries, and emergency department visits, did not change. The authors conclude that the change in payment structure did not impact surgical safety.

Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.

… not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist … remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding …

This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.

This direct observation study revealed that surgeons performed with less dexterity and made more errors when distractions were present in the operating room compared to when no distraction occurred, and this effect was more pronounced in those with less experience. Consistent with prior work on interruptions and distractions, this finding underscores the need to augment health care work environments to improve safety.

… supporting the impact of the World Health Organization's surgical safety checklist was a cohort study that found a significant reduction in mortality associated with the use …

This systematic review found that patients who experience adverse events in intensive care units (ICUs) have significantly longer hospital and ICU stays. According to this study, the effect on mortality is less clear as the evidence linking adverse events to ICU deaths have been mixed and unreliable.

Under the Affordable Care Act, hospitals will soon face financial penalties for high readmission rates. This qualitative study used semi-structured interviews with hospital administrators to outline strategies for reducing unnecessary readmissions.

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.

Attending surgeons and surgical residents in Iran cited concerns about malpractice litigation and fear of losing patients' trust as reasons why they did not disclose errors to patients.

This article explains how health information technologies can enhance understanding of and contextualize data rather than just collect it. Case studies demonstrate how hospitals can use this approach to improve safety and quality.

This study found that inadequate training and supervision of medical students and interns contribute to preventable urinary catheterization injuries.