Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.

Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.

Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.

The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.

All nursing homes certified by the Centers for Medicaid & Medicare Services (CMS) are required to submit select patient safety data which is used to calculate quality ratings. This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure ulcer-related hospital admissions. Similar to earlier research on self-reported falls data, correlations between the self-reported and claims-based data was poor. The authors suggest alternate methods of data collection may provide the public with more accurate patient safety information.

Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.

The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.

The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.

Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.

The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.

Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.

Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.

Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.

Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.

The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.