Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight. Findings indicate that patients who spent an overnight in the ED had a higher in-hospital mortality rate, increased risk of adverse events, and longer length of stay; this risk was exacerbated for patients with limited functional status.

The surgical time out is an effective strategy to reduce errors and improve team communication but full team participation remains a challenge. This article describes a Plan, Do, Study, Act project of developing and implementing a white board time out checklist to encourage all operating room personnel to participate. A significant increase in the number of completed time out items was seen after implementation.

The quality improvement and patient safety (QIPS) curriculum is increasingly being added to resident education, but implementation and quality of these programs varies. In this study, continuous improvement specialists (CIS) were embedded in resident teams to create an A3, a quality improvement tool. A key component to the QIPS curriculum was aligning resident projects with quality improvement efforts already underway in the department.

Previous research has emphasized suicide prevention in inpatient mental health settings, but less is known about suicide in outpatient settings. Using longitudinal data from 2013 to 2017, this study found no relationship between overall quality of outpatient mental healthcare and suicide rates among patients treated by the Veterans Health Administration healthcare system.

Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the United States. This article describes the development of the Child Health PSO and how it evolved into a learning network through alignment around a common goal, collaboration, and information sharing with high levels of engagement from participating children’s hospitals.

Communication within teams is central to safe care delivery, crisis management, and staff well-being. This report shares the experience of one hospital that used technology to enhance information-sharing as a strategy to reduce clinician burnout in times of uncertainty and crisis.

Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.

This article describes the experience of one hospital in eastern Massachusetts implementing rapid response capabilities in an innovative, hybrid acute care-intensive care unit. Health system leadership used failure modes and effect analysis, process mapping, and on-site walkthroughs to identify potential hazards and opportunities for risk mitigation, as well as in situ simulation drills to facilitate team training.

In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.

… not disclosing information. Disagreement with a clinician's recommendation or failure to understand a clinician's instructions were common. Patients most often did not …

Calculation errors in weight-based dosing can lead to serious adverse medication events in children. This simulation study randomized residents in a pediatric emergency department to receive either a reference book with precalculated weight-based dosing for medications or a card providing dose per body weight that required manual calculation. Each resident completed two scenarios, one with the precalculated doses and one requiring medication calculations. Although there was no statistically significant difference in overall error rates, errors for continuous infusions and 10-fold errors for bolus medications were significantly lower in the precalculated dose group. This study demonstrates that precalculated medication doses may decrease rates of certain high-priority medication prescribing errors. A past WebM&M commentary discussed an incident involving a pediatric dosing error.

This guideline reviews recommendations and best-practice statements from an international consensus committee on sepsis treatment and management to guide safe care for patients with sepsis or septic shock.

Surgical site infections are a common complication, and they can have serious consequences. This consensus statement provides a set of recommendations to prevent surgical site infections in gynecologic surgical care that focus on readiness, recognition and prevention, response, and reporting and systems learning. The authors highlight the importance of teamwork and communication to achieving success and suggest that components of the bundle are applicable across a variety of surgical settings.

Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.