Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

Healthcare has borrowed many safety practices from aviation such as checklists, crew resource management, and safety culture. In this study, interviews with aviation experts identify non-technical skills that leaders require in a safety culture environment which the authors adapt for surgical leaders. The core attribute was "humble confidence," with three additional domains: management of risk, management of opportunity, and management of people. The authors developed the Safety Leadership Assessment Matrix (SLAM) to assess these non-technical skills in surgeon leaders.

Shortfalls in electronic health record (EHR) interoperability can threaten patient safety. Chief clinical information officers (CCIOs) participating in semi-structured interviews highlighted the ways in which limited EHR interoperability adversely impacts patient health and safety by hindering care coordination and creating inefficient care processes. Participants noted that solutions are necessary at both the technical (e.g., user-centered design) and policy levels.

Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and improve antimicrobial and opioid stewardship. This review identified 21 studies describing interventions to encourage prescribers to include indications for medications. In addition to patient safety benefits, several risks and drawbacks were uncovered, such as potential loss of patient privacy or alert fatigue.

Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.

Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.

Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.

Electronic health records (EHR) systems frequently interact with EHRs in other organizations, between clinical settings (e.g., in-patient and out-patient), or with devices (e.g., smart pumps). In this review, 12 studies were identified that examined the effect of EHR interoperability on patient safety. While EHR interoperability was shown to improve patient safety, outcome measure heterogeneity limits measuring true effects.

Patient use of digital and online symptom checkers is increasing, but formal validation of these tools is lacking. This systematic review identified ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and ophthalmic conditions. The authors concluded that the diagnostic and triage accuracy of symptom checkers varies and has low accuracy.

As patients increasingly access their electronic health records, they often identify errors requiring correction. This survey of 445 patients in the United Kingdom found that the majority of patients are willing and able to identify and respond to errors in their electronic health records, but information-related and systems-related barriers (e.g., limited understanding of medical terminology, poor information display) disproportionately impact patients with lower digital health literacy or language barriers.

The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.

Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.

This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

Patient access to electronic health records (EHRs) can improve health outcomes but is not without concern. This survey of users of a patient portal providing online access to EHRs identified several barriers to understanding information contained in their electronic records, including medical terminology, interpretation of test results, and information display. These barriers signal potential avenues for improving systems providing patient access to their health records.

This systematic review evaluated the impact of providing patients with access to electronic health records (EHR) on measures of quality of care (i.e., patient-centeredness, effectiveness, efficiency, timeliness, equity, and safety). Meta-analysis found that sharing EHRs with patients is effective in reducing HbA1c levels; the included studies generally found positive effects on patient-centeredness, health outcomes, and adherence to preventative services. However, the authors concluded that more methodologically robust studies are necessary to quantitatively assess the impact of sharing EHRs with patients.  

This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.

An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.

This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies.  Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.

Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.

This article reviewed 74 academic and 10 policy resources, as well as interviewed 13 experts, to understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Findings highlight the need for standardized methods to use and report complaints data, novel policy strategies, and analysis strategies to generate actionable learning insights and translation into quality improvement by affecting leadership and safety culture are discussed.