Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.

Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.

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.

Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.

Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

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.

Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.

Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

Children with intellectual disabilities can be at higher risk for patient safety events. Based on semi-structured interviews and focus groups with healthcare professionals, this study describes several themes regarding healthcare professionals’ perspectives about patient safety considerations when caring for children and young people with intellectual disabilities. Findings underscore the importance of considering additional vulnerabilities, improving engagement with patients and families, and mitigating negative attitudes and biases.

Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.

Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.

Hierarchy as an organizational or team structure is known to affect patient safety. This editorial examines the impact a strict chain of command can have on communication and awareness-raising actions in the care environment. The author illustrates how a staff’s ability to contribute to care goals and raise concerns is enhanced when all are respected as having valuable insights without deference to role or education level.

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.

Structural racism and the resulting negative social determinants of health (SDoH) impact the quality of care that children of color receive. This commentary presents strategies for pediatricians to eliminate structural racism at the system- and organizational-levels such as ensuring access to equitable healthcare facilities, creating an environment of inclusion and respect, and eliminating use of algorithms that include race or ethnicity and result in inequitable treatment.