Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.

Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations. 

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

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.

Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.

Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.

Medication administration is a complex process with many opportunities for error. Using the Event Analysis of Systemic Teamwork (EAST) model, researchers identified opportunities to improve medication administration system performance and promote patient safety. The authors discuss the networks involved in medication administration (e.g., task network, social network, information network) and how the complexities involved in each network contribute to medication administration errors.

Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.