Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

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).

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 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.

Cognitive biases can influence treatment approach at the end of life. The goal of this study was to determine whether treatment approaches (e.g., palliative care to aggressive treatment) were associated with clinician cognitive biases in acute care settings for patients with advanced dementia and comorbidities. Representativeness, availability, and anchoring biases were associated with treatment approach in this hypothetical patient case; moral characteristics of the clinician were not associated with treatment approach.

Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.

Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes. 

Intimate partner violence (IPV) victims and survivors frequently access healthcare, but don’t always receive trauma-informed care or referrals to IPV resources. This study asked IPV survivors what patient safety meant to them. They described it as care that contained: 1) compassionate and/or trauma-informed care; 2) physically safe spaces; and/or 3) a connection to social resources. Survivors described ways healthcare providers could improve IPV safety.

Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.

Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.

Accurate dosing and administration of liquid medications to children can be difficult for parents or caregivers. In this study, family caregivers and clinicians described their experiences at hospital discharge relating to both general and liquid-specific medication counseling. Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. Caregivers were not always shown how to draw up liquid into the syringes leading to them feeling uncertain about giving the correct dose. Health literacy and speaking languages other than English were also described as challenges.