Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.

Ensuring staff have a safe work environment and patients receive safe care are separate but complementary goals. This study describes how elected politicians and healthcare leaders balance workplace safety regulations and patient quality and safety goals in long-term care facilities. Tensions between the groups were identified (e.g., where leaders see flexibility, elected leaders see vagueness). Study themes include creating and improving channels for communication, and clear delineation of roles and responsibilities.

Safety culture is recognized as an essential component of reducing or preventing errors and improving overall patient safety. This commentary calls for greater consistency in defining and measuring safety culture across settings. The authors describe challenges faced by patient safety professionals and researchers, and offer recommendations on overcoming them.

Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

Patient safety incident investigations are important tools for identifying failures and facilitators of patient harm. This article provides an overview of the regulatory bodies in Norway that are involved in investigating adverse events and how the language used during these investigative activities can support or impede the process.

… such as delays in access or diagnosis. … Averill P, Vincent C, Reen G, et al. Conceptual and practical challenges …

The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.

Leadership engagement is key to achieving patient safety goals. When it comes to improvement and innovation, healthcare organizations must balance multiple, sometimes conflicting, aims, such as cost, clinician wellbeing, and patient safety. This commentary outlines how healthcare organizations can manage multiple complex aims in relation to improvement and innovation projects. Four principles of managing multiple aims and five key strategies for practical action are described.

… J Patient Saf Risk Manag … The July effect is a phenomenon … to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J …

… effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other … or other ancillary services. … Marang-van de Mheen PJ, Vincent C. Moving beyond the weekend effect: how can we best …

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

… J Patient Saf. … This qualitative study conducted in Norway … GS, Macrae C, et al. Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience. J Patient Saf. 2021;17(2):122-130. …

Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.

… Arch Dis Child … In the second of a two-part series , using examples from newborn units, the authors present a framework for supporting practitioners in low-resource … and (4) enhancing responses to hazardous situations. … Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child.  Epub …

Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.

… for transforming health systems across the world – a country-specific blueprint for change, tangible steps to … to improve safe care delivery.   … Braithwaite J, Vincent C, Garcia-Elorrio E, et al. Transformational improvement in quality care and …

… J Patient Saf Risk Manag … In this editorial, patient safety … safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, … the dark side and the sunny side for patient safety. J Patient Saf Risk Manag. 2020;25(4):137-141. …

… J Patient Saf … Based on qualitative data from healthcare … this study examined how next-of-kin in cancer care play a role in organizational resilience. Findings show that … and potential to anticipate. … Bergerød IJ, Braut GS, Wiig S. Resilience from a stakeholder perspective: the role …

This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.

The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.