Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

Patient engagement is cornerstone to safe care initiatives. This qualitative study including 28 acute care patients explored how patients contribute to safety and highlight the importance of reassurance and vigilance.

The COVID-19 pandemic dramatically changed healthcare delivery and impacted the ways healthcare teams function. Using interprofessional focus groups, this study explored the perspectives of medical intensive care unit (MICU) team members on the role of TeamSTEPPS® during the first year of the COVID-19 pandemic. Participants discussed how TeamSTEPPS® impacted teamwork and communication through shared mental models, trust, role definition, and effective briefing/debriefing and transitions of care strategies. Participants also identified several challenges to TeamSTEPPS® implementation related to the MICU environment, the ongoing pandemic, power dynamics, and patient acuity.

While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.

Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).

Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.

Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.

Care left undone (also called missed care, unfinished care, and implicitly rationed care) is associated with lower perception of safety culture and increased adverse events. In this study, more than 2,200 pediatric nurses were asked about care tasks left undone in their most recent shift and a variety of environmental factors (e.g., perception of their work environment, risk of burnout). The most frequently omitted task was comfort/talk with patients, and the least frequently omitted task was pain management.

The COVID-19 pandemic dramatically changed healthcare delivery across all settings. This qualitative study explored perceptions of patient safety in intensive care among nurses redeployed to intensive care settings during the pandemic. Nurses reported increases in patient safety risks during the pandemic, which were largely attributed to changes in nursing skill mix and poor continuity of care.

Medication errors are a global patient safety concern, particularly in high-risk areas like the intensive care unit. This umbrella review synthesizes medication interventions into two areas: systems (e.g., smart pumps) and processes (e.g., medication review). The authors highlight the importance of using multiple strategies when working to improve medication safety in the ICU.

Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.  

Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.