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.

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.

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.

Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.

Improved nurse staffing ratios and nursing skill mix have been linked to improved safety outcomes. This retrospective cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events.

Staffing and nursing time at the bedside play a role in missed nursing care. This study focused on the role of COVID-19 on staffing and nursing time at the bedside and, therefore, on missed nursing care in labor and delivery units. During a peak of the pandemic, this study of obstetrics nurses found perceptions of nursing time at the bedside and adequate staffing played a significant role in missed nursing care.

Cesarean delivery can lead to increased maternal morbidity and mortality. In this repeated cross-sectional study, physicians, nurses, and midwives were surveyed about their attitudes towards elective induction of labor before and after results were published from a large, randomized trial (Randomized Trial of Induction Versus Expectant Management, or ARRIVE) supporting elective inductions at 39 weeks to reduce the likelihood of a cesarean. Findings indicate that physician attitudes about induction shifted in favor of induction after ARRIVE, whereas nurse attitudes did not change. Qualitative analyses revealed four themes regarding attitudes towards induction- the importance of timing, identifying who should receive inductions, the need for clear protocols and more staff, and improvements to the induction of labor processes. 

Family involvement in care can have mixed results for patient safety. Interviews with nurses show seven ways families can hinder safety and ten ways they improve safety. The risk of infection was the greatest safety threat and being a unique source of information helped increase patient safety. Interestingly, "greater workload for nurses" was identified as a facilitator of patient safety, potentially, as it lowered the stress experienced by the nurse and increased family satisfaction and positive involvement.

Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.

Promoting a culture of safety has been identified as an intervention to improve patient safety in long term care. In this study, focus groups with nursing, social work, and support staff were conducted to determine how the safety culture could be improved in four long term care facilities in Indonesia. Proposed interventions include new hire orientation, training, improvement in facility design, and increased security staff.

Missed nursing care is a key indicator of patient safety and has been linked to safety climate. Survey responses from 3,429 labor and delivery nurses from 253 hospitals across the United States found an average of 11 of 25 aspects of essential nursing care were occasionally, frequently, or always missed. Higher perceived safety climate was associated with less missed care. The authors discuss the importance of strategies to reduce missed care, such as adequate nurse staffing, ensuring nonpunitive responses to errors, and promoting open communication.

Fatigue is a known contributor to adverse events and near misses. Researchers summarized 38 studies on the impact of fatigue on nurses’ medication administration errors (MAE) or near misses. Thirty-one studies reported that long hours, shift work, overtime, and/or poor sleep quality contributed to MAE and near miss, but results and methods of measuring fatigue were inconsistent.

Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.  

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.