The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review highlights recent research conducted within a Safety II and resilience framework such as Learning from Excellence and debriefing "what went right" after simulation training. The authors suggest learning from errors or what goes right should be reframed simply as learning.

The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.

A culture of safety is essential to the delivery of high-quality, safe healthcare. This scoping review including 34 studies found that patient safety culture scores were generally associated with reduced adverse event rates, but the authors note a paucity of research from primary care settings and low- and middle-income countries as well as a need for longitudinal studies using standardized measures to better examine this relationship.

Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.

Psychological safety promotes speaking up and error reporting in the workplace, and many system and individual characteristics interact to promote or hinder reporting behavior. This review highlights individual characteristics that encourage error reporting, (confidence and positive perception of self, the organization, and leadership) or create barriers (self-preservation associated with fear and negative perceptions of self, the organization, and leadership).

Although direct-acting oral anti-coagulants (DOACs) are considered safer than warfarin, DOAC dosing is complex and can lead to medication errors. This narrative review discusses the clinical consequences of potentially inappropriate inpatient prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment.

Incorrect patient registration, application of the wrong label, and blood draw from the wrong patient can all cause blood transfusion errors. This systematic review identified six studies related to nursing and blood transfusion safety. Errors fell into two broad categories - human and environmental factors, and education. Initial and continuing education for all members of the team, including registration staff, should be considered to improve and maintain transfusion safety.

Older adults are particularly vulnerable to medication-related safety events. This systematic review including 21 studies on medication-related problems in in older adults identified several types of safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead to poor outcomes among older adults in nursing homes, inpatient care, and community settings. The authors found the classes of medication related problems are similar to studies from a decade ago, suggesting that more intensive monitoring is needed.

Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

Overlapping surgery – when surgeons schedule distinct procedures on different patients concurrently – has raised safety concerns but recent studies have not found significant differences in perioperative outcomes. This retrospective cohort study including over 87,000 surgical cases found that overlapping surgeries increased operative times but did not lead to increased in-hospital mortality, adverse events, or readmission rates when compared to nonoverlapping cases.

Vulnerable populations, such as those with limited English proficiency, minoritized race or ethnicity, migrant populations, or patients qualifying for public insurance, may be at higher risk for adverse health events. In this review, researchers sought to identify frequency and causes of diagnostic error of vulnerable populations presenting to the emergency department with cardiovascular or cerebrovascular/neurological symptoms. Black patients presenting with cardiovascular symptoms had significantly higher odds of diagnostic error. Other demographic factors did not show similar associations, nor did studies of patients with cerebrovascular/neurological symptoms.

Cognitive biases can threaten patient safety in a variety of ways. This narrative review summarizes the common cognitive biases in surgical care and how they threaten patient safety, including delays in diagnosis and treatment, unnecessary surgeries, and intraoperative errors and complications. The authors also discuss cognitive debiasing strategies to mitigate the impact of cognitive biases.

Health care-associated infections continue to be one of the most common health care-related complications. This systematic review including 67 studies identified several cost-effective interventions addressing health care-associated infections, including screening high-risk individuals, universal decolonization in intensive care units, hand hygiene, environmental cleaning, and surveillance. The authors found limited evidence evaluating the cost-effectiveness of other strategies such as education and training or use of personal protective equipment.

Artificial intelligence (AI) is increasingly used to identify and prevent patient safety threats. This review focuses on AI used to reduce medication errors in the primary care setting. Most studies targeted the prescribing stage, and the main category of AI was computerized decision support system.

Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.

Debriefing after clinical events is an important opportunity for critical learning, process improvement, and enhancing team communication. This systematic review of 21 studies synthesized findings regarding the attributes and evidence supporting the use of clinical debriefing tools. While all of the evaluated tools included points related to education and evaluation, few tools included a process for implementing change or addressed staff emotions. The authors include recommendations for clinicians, educators and researchers for teaching, implementing and evaluating clinical debriefing tools.

In medical education, the “hidden curriculum” refers to the influence of offhand comments, behaviors, and attitudes of senior clinicians on the formation of a student’s professional identity. This scoping review identified five papers examining the hidden curriculum in pharmacy education. The studies identified several approaches to address the hidden curriculum during pharmacy training, such as better integration of formal and informal training activities, encouraging positive mentor:mentee relationships between students and practicing pharmacists, and cultivating professionalism.

Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.