Near-misses or “good catches” are incidents that could have resulted in patient harm but did not due to it being caught at the last minute or through sheer luck. Reporting near-misses can help organizations learn and enact changes if necessary, but near-misses are not frequently reported. This study presents enablers and barriers to reporting near-misses.

The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

Home care settings have unique patient safety challenges. This qualitative study including home care clinicians, inspectors, and family caregivers in Iran highlights that the healthcare team plays an important role in creating and promoting safe home care, including the use of individual risk assessments and mitigation of risk factors.

Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.

Simulated hospital rooms have been used in medical education to identify potential safety threats. In this study, pharmacy students participated in a team-based simulation to identify potential latent errors and then completed a system thinking survey. Survey results indicated students had a good understanding of systems thinking, but only identified about half of the potential errors in the simulated room.

Promoting a culture of safety has been identified as an intervention to improve patient safety in long term care. In this study, focus groups with nursing, social work, and support staff were conducted to determine how the safety culture could be improved in four long term care facilities in Indonesia. Proposed interventions include new hire orientation, training, improvement in facility design, and increased security staff.

If reported, near misses – also called “good catches” – present opportunities for healthcare organizations to learn about potential errors, identify system improvements, and improve safety culture. This mixed-methods study including 199 nurses, who worked in COVID-19 units, found that intent to report near misses was high (78%) but follow-through on reporting was low (20%). Qualitative analyses highlight the role that personnel/physical/mental overload, poor departmental organization, and fear of punitive measures play in underreporting near-miss events.

Empowering patients to ensure safe care is one component of patient engagement. This analysis of 456 patients found that self-efficacy increased patient engagement in their care and led to increased patient safety.

The World Health Organization’s Surgical Safety Checklist has been used in populations around the globe to reduce surgical complications and improve operating room teamwork. This mixed methods study involved nearly 150 surgical nurses in Turkey. Nurses reported inconsistent use of the checklist, described barriers to its use, and offered suggestions to increase compliance with completion.

Hospitals, pharmacies, and organizations have developed numerous strategies to prevent look-alike/sound-alike medication mix-ups, but these errors continue to occur. This article suggests a human factors approach by changing the shape of the container for each medication class-type, thus reducing clinicians’ cognitive load. Importantly, drug manufacturers would need to agree on container shapes to prevent confusion when drugs are ordered from different suppliers.

Context, such as patient, clinician, location, or specialty, can affect the type and frequency of diagnostic errors. In this novel study, the diagnostic errors of a cohort of clinicians who practice in multiple locations (i.e., outpatient and emergency department) with different referral types (i.e., scheduled visit, urgent visit, emergency visit) was evaluated. Using the Revised Safer Dx instrument, researchers identified significantly more diagnostic errors in patients with scheduled visits compared to urgent or emergent referrals. The results indicate, that among clinicians in the same specialty, it may be contextual factors (i.e., referral type) that affect diagnostic errors rather than specialty.

Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.

Cognitive biases can impede diagnostic decision-making and contribute to diagnostic delays and patient harm. This study explored the types of cognitive biases contributing to diagnostic errors in emergency rooms in Japan. The most common biases reported were overconfidence, confirmation bias, availability bias, and anchoring bias. Findings indicate that most diagnostic errors involved overlooking another disease in the same organ group or related organ (e.g., diagnosing headache rather than stroke).

Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.

Improving diagnostic reasoning skills can reduce diagnostic errors. These authors discuss how insight – or the spontaneous emergence of the correct answer at a later point in time – can be incorporated into the diagnostic process and approaches to nurturing insight through existing strategies (e.g., cognitive forcing functions, mnemonics) and enhancing both critical and creative thinking.  

Strong patient safety culture is a cornerstone to sustained safety improvements. This cross-sectional study explored nurses’ perceptions about patient safety culture. Identified areas of strength included non-punitive responses to errors and teamwork, and areas for improvement focused on supervisor and manager expectations, responses, and actions to promote safety and open communication. The authors highlight the importance of measuring patient safety culture in order to improve hospitals’ patient safety improvement practices, overall performance and quality of healthcare delivery.

Disruptive behaviors are discouragingly present in health care. This commentary discusses evidence examining the impact of unprofessional behaviors on safety and clinical care. The authors suggest areas of exploration needed to design reduction efforts such as teamwork, the Safety I mindset and targeting of the root influences of impropriety.

Speech recognition software is a potential strategy to reduce documentation burden and burnout. This study compared the accuracy handwritten nursing notes versus online and offline speech recognition software. Findings indicate that the speech recognition software was accurate but created more errors than handwritten notes.

Balancing autonomy and supervision is an ongoing challenge in medical training. This study explored how residents’ networking with senior physicians influences advice-seeking behaviors and medical errors. Findings suggest that residents made fewer errors when they consulted with fewer senior physicians overall and consulted more frequently with focal senior physicians (i.e., physicians sought out by other residents frequently for consults).