Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.

Medication errors in pediatric patients can have serious consequences. This systematic review identified three studies examining interventions to improve medication safety in pediatric inpatient settings. Although the three interventions – a mnemonic device, a checklist, and a specific prescribing round involving a clinical pharmacist and a doctor – reduced prescribing errors, the studies did not assess weight-based errors or demonstrate reductions in clinical harm.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

The goal for health care organizations to attain high reliability is established but elusive. This article shares insights drawn from a Veterans’ Health system effort to support high reliability. The approach used centered on five components focusing on leadership, data systems, implementation, training, and safety culture.

Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.

Health systems often implement innovative quality improvement and patient safety initiatives, but the longevity and sustainability of these initiatives remains a challenge. This scoping review explored the factors which enable and hinder sustainability of hospital-wide quality improvement (QI) initiatives. Three overarching themes were identified – the role of (1) people, including the organizational and leadership teams, as well as frontline staff implementing the QI initiatives, (2) processes, such as local and organizational integration and planning for sustainability, and (3) the organizational environment such as resources, infrastructure, and hospital culture.

Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.

Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.

Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.

Health systems often consider return on investment (ROI) when considering implementation of quality improvement and patient safety interventions (i.e., costs saved by preventing medical errors or improving quality of care). This systematic review explored how ROI concepts have been used in studies assessing large-scale quality improvement programs.

Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

In response to the increase in opioid deaths, the Centers for Disease Control and Prevention (CDC) released the Guidelines for Prescribing Opioids for Chronic Pain in 2016, with an update released in 2022. This study reports on the CDC Opioid QI Collaborative which was launched to identify successful evidence-based strategies for implementing the guidelines. The challenges and strategies described in the publication can be used by health systems to accelerate implementation of the guidelines.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.