The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.

Psychological safety and willingness to speak up about safety concerns are cornerstone to safety culture. Using four clinical vignettes that described the same case in the Emergency Department but differed with respect to whether a nurse spoke up with treatment-related concerns or remained silent, researchers examined healthcare team members’ perspectives of psychological safety and discussed the importance of organizational and team leadership that encourages and supports speaking up behaviors.

Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.

Resiliency and proactive safety behaviors can improve safety in the perioperative environment. In this article, the authors describe safety attitudes of perioperative staff after participating in a proactive activity, One Safe Act (OSA). Most participants reported the OSA activity would change their work practices, improve their work unit's ability to deliver safe care, and demonstrate their colleagues' commitment to patient safety.

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. 

The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.

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.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

A culture of safety is essential to the delivery of high-quality, safe healthcare. This scoping review including 34 studies found that patient safety culture scores were generally associated with reduced adverse event rates, but the authors note a paucity of research from primary care settings and low- and middle-income countries as well as a need for longitudinal studies using standardized measures to better examine this relationship.

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.

Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This report compiles reports submitted in 2022 and compares results to previous years. There was a decrease in the total number of reports submitted, but serious and high harm events increased. The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed by Complication of Procedure/Treatment/Test, Medication Error, and Fall.