While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.

Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.

… J Patient Saf … This article reviews the theory behind the … and unsafe acts threaten patient safety. … Wiegmann DA, L JW, T NC, et al. Understanding the "Swiss cheese model" and its …

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Although computerized physician order …

This quality improvement initiative used human factors approaches including failure mode and effect analysis, event review, and root cause analysis to successfully reduce the rate of specimen mislabeling in an inpatient setting. This study highlights the importance of re-examining longstanding work processes to augment safety.

… Journal of general internal medicine … J Gen Intern Med … This cost analysis of the 2011 duty hour …

A recent Institute of Medicine (IOM) report recommended significant changes to resident physicians' work hours to improve patient safety. These recommendations included eliminating extended duration shifts or scheduling nap times during extended shifts, decreasing resident workload, and strictly adhering to the 80-hour weekly work limits originally implemented in 2003. The implementation of the IOM recommendations would cost teaching hospitals approximately $1.6 billion, according to this analysis. However, due to a lack of clear evidence on the safety effects of duty-hour reduction, the authors were unable to accurately estimate the cost savings to society if adverse events were reduced. The accompanying editorial notes the relative lack of evidence supporting additional duty-hour reductions and calls for further study of the relationship between duty hours, handoffs, and patient safety.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Incident reporting (IR) systems serve as …

… Journal of general internal medicine … J Gen Intern Med … Adoption of smart infusion pump technology …

… limitations of their study design may have contributed. … Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous …

Despite mandates for US hospitals to maintain incident reporting systems, little is known about the utility of the data collected. This study linked incident report and discharge databases at two hospitals to examine how frequently reports were filed and what types of incidents were documented. The vast majority of reports were filed by nurses, with less than 2% filed by physicians (a problem noted in prior research). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to procedures. A prior commentary proposed a theoretical framework for using incident reporting data to improve safety.

… Journal of general internal medicine … J Gen Intern Med … Since implementation of the mandate for …