Falls are a persistent threat to patient safety and effective reporting of this adverse event can assist in understanding important gaps in care. This report examines the incidence of Medicare home health patients experiencing falls with major injury resulting in hospitalization that were not reported as required. 55% of falls were not documented thusly negatively impacting the viability of Care Compare as a reliable public resource for this information.

Health care has long held commercial aviation as a beacon to guide patient safety improvement work. This article examines how well aviation safety  mechanisms map to medical care safety efforts such as checklists, just culture and operating room black boxes.

Large-scale data analysis provides insights to generate evidence-based improvement action. This collection of reports provides access to investigations of the impact of healthcare-related harm events in Department of Health and Human Services (HHS) programs and across the United States health system. This set of publications not only examines weaknesses but provides recommendations for improvement on topics such as gaps in fall reporting by home health agencies, Medicare adverse events and the viability of payment incentives as a strategy for medical harm reduction.

Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.

US Food and Drug Administration regulation and review is noted as having gaps in process that can affect patient safety. This article discusses reasons for the reluctance of physicians to fully embrace the use of artificial intelligence tools approved by the FDA in their practice. The concerns include lax regulation, poor product development transparency and lack of robust real-world accuracy data.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 

Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Fall 2023 hospital safety grade results, documenting a reduction in both patient satisfaction scores and healthcare associated infection rates to pre-pandemic levels, are available. 

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held January 16, 2024.

Diagnostic errors in hospitals are the focus on continued improvement efforts as they are common, costly, and harmful. This last in a three-part series of webinars will focus on existing learning strategies to improve diagnosis in hospitals. Dr. Divvy Upadhyay is the featured speaker.

Inspired by the research and leadership of Dr. Robert Wears, this award annually recognizes individuals, teams or organizations that examine the applications of safety science concepts to improve medicine. Nominations for the 2024 award must be submitted by January 2, 2024.

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.