Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.

Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients at risk for adverse events. This observational study set in a high-complexity hospital in Spain found that patients with inappropriate hospital admissions (IHA) have a higher risk of subsequent adverse events, contributing to longer stays and additional costs.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.

Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.

Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.

The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.

Missed nursing care (MNC) refers to needed nursing care that is delayed, partially completed, or not completed at all, and can result in adverse events. This systematic review summarizes missed nursing care in emergency departments (ED). Causes of MNC include overcrowding and patients with complex care needs, which may result in medication errors, pressure injuries, or patient deterioration.

The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.

Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.