National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment. 

Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician communication. This article highlights efforts to understand implicit biases in health care professionals. It discusses initiatives and tools in development to reduce the presence of unconscious bias in health care.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

The COVID-19 pandemic led to the rapid expansion and adoption of telehealth. The authors of this article discuss how to leverage the increased use of telehealth and propose a new organizational telehealth program model to help organizations develop and sustain safe, equitable, and high-quality telehealth programs.

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.

The COVID-19 pandemic led to unprecedented numbers of patients seen in the emergency department (ED), some who had COVID-19, some who had a different diagnosis, and some who had both. This study analyzes patients who presented to the ED with COVID-19 and signs of another diagnosis that was missed. Approximately one-third of patients with a second concurrent diagnosis experienced a diagnostic delay. Factors that may have influenced the missed diagnosis include ED overcrowding and anchoring heuristics.

Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.

Patients with diabetes may not be aware of their condition and therefore may not seek timely care. In this pilot study, patients presenting to the emergency department at risk of type 2 diabetes were flagged by the electronic health record. Clinicians could then add hemoglobin A1c (HbA1c) to scheduled blood draws. Of the patients with elevated HbA1c levels contacted by study staff, three-quarters were not aware of a previous diabetes diagnosis.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

Missteps in the labeling and registration of child injury as abuse can result in harm for patients and families. This article discusses the impact of implicit bias on reporting actions and shares tactics to minimize the influence of cognitive error on recognizing and reporting of child mistreatment.

Due to the infectious and deadly nature of COVID-19, heath care facilities were forced to change many of their person-centered policies, including restriction on visits from family and friends. This review highlights factors that impacted hospitalized patients during COVID-19. Thirty-two studies were identified and classified into three main factors: concern about the patient’s well-being during hospitalization, communication and interaction between patients, families, and care team, and the impact on the health care organization.

Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.