The latent nature of failure in health care is enabled by organizational inability or unwillingness to listen and respond to the concerns of patients, families, and clinicians. This commentary discusses a rare criminal event in the British National Health System (NHS) and the factors that allowed continued criminal activity to occur over time.

Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.

The COVID-19 pandemic resulted in many changes to the delivery of healthcare. Using data submitted to one Patient Safety Organization, this study examined patient safety events and concerns related to proning patients during the COVID-19 pandemic. Issues identified included medical device-related pressure injuries and device dislodgement, concerns with care delivery, staffing levels, and acuity issues.

Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.

Healthcare-associated infections (HAIs) continue to be a preventable safety problem. This study explored the correlation between hospitals’ Leapfrog Hospital Safety Grade and Magnet designation on measures of patient safety, including healthcare-acquired infections (HAIs). The researchers found that Leapfrog safety scores were higher for Magnet-designated versus non-Magnet-designated hospitals – particularly for structural measures – but Magnet-designated hospitals did not have lower HAI rates.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.

Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.

Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.

By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).

The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was a seminal moment in the patient safety movement. This bibliometric analysis found that the report has been mentioned in over 20,000 scientific publications since 2000, but that the themes of recent research do not necessarily align with the initial focus of the IOM report. For example, research on incident reporting and systems approaches to improving safety are underrepresented relative to their emphasis in the IOM report.