Becoming a high-reliability organization (HRO) to improve patient safety is a goal of the Veterans Heath Administration (VHA). This commentary describes the VHA's implementation strategy and progress since 2019 at the patient, employee, and organizational levels. The three pillars of the VHA's HRO strategy are leadership commitment, a culture of safety, and continuous process improvement. Challenges associated with the COVID-19 pandemic are also discussed.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

Radiologic diagnostic errors can result in delayed or unnecessary treatment. This paper describes five types of cognitive biases, with accompanying case study and images, that result in misdiagnosis. Both individual education and system-level solutions are described.

Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations. 

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.

The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.

Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.

AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.

Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.  

Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.

Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.