Involvement in patient safety incidents can erode patient trust in their own physicians and the healthcare system. This article summarizes the estimated frequency of lost trust after patient safety incidents, external factors contributing to mistrust, and approaches to restoring trust after incidents.

Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.

Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate sentinel events. In this study, members of an RCA committee were interviewed before and after an RCA investigation to elicit their experiences and assess compliance with the Norwegian RCA process. Organizational factors and team composition presented challenges, particularly the inclusion of staff closely involved with the incident under investigation.

Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.

Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.

Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.

Patient safety improvement efforts involve financial expenditures, which means that hospital leaders must evaluate their return on investment. This study examines the association of several quality-of-care measures and hospital profitability as measured by patient revenue per adjusted discharge. Better patient satisfaction, lower readmission rates, and three of the four Hospital Value-Based Purchasing Program (HVBP) domains were associated with improved financial outcomes.

Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.

Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.

Transfusion errors can lead to serious patient harm. In this retrospective analysis of transfusion medical records and related documentation, researchers examined transfusion incident characteristics and logistical errors associated with incidents. Common logistical errors included elevated hemoglobin, inadequate bedside tests, inadequate patient identification, and laboratory errors.

Primary care plays an important role in identifying, avoiding and mitigating patient safety issues. This report highlights several patient safety priorities and how small (<10 providers) primary care practices can promote safe practice and outcomes for their patients.

Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).