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.

Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.

Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.

AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.  

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.

The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.

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.

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.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

The “July effect” is a widely held, yet poorly studied, belief that the quality of care delivered in teaching hospitals decreases during the summer months due to the arrival of new trainee physicians. Using national inpatient stay data from 2018, this study found that the risk of postpartum hemorrhage among patients treated at teaching hospitals was significantly higher during the first six months of the academic year (July to December) compared to the second half (January to June). The authors recommend future research examine whether postpartum hemorrhage is associated with resident work hours, technical deficiencies, or unfamiliarity with hospital practices, and emphasize the importance of monitoring and clinical training to mitigate the impacts of the “July effect.”

Simulation-based training provides a safe environment to learn technical and nontechnical skills (NTS) such as communication and teamwork. This article describes the development of nontechnical, simulation-based crisis scenarios in cardiothoracic surgery. Cardiac surgeons, cardiac anesthesiologists, cardiac perfusionists, and cardiac operating room nurses from all surgical cardiac centers in the Netherlands participated in the development of 13 crisis scenarios. The list of selected and non-selected scenarios and an example scenario design template are provided.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor. 

Anesthesiologists frequently hand off care of complex, often unstable patients, which can introduce patient safety risks. This systematic review examined the education components of studies seeking to improve anesthesiology handoffs. The authors identified marked heterogeneity in the use of established curriculum development best practices and concluded that more than half of the medical education interventions were of low quality. The authors identify challenges that could be addressed to improve future educational interventions.

Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

Medication timing errors can lead to too-frequent or missed doses of medications and cause patient harm. This systematic review including 23 articles found that medication administration timing errors (defined in the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur in up to 72.6% of medication administration errors.