Research and medical practice are negatively affected by systemic and implicit bias. This commentary discusses this phenomenon in the mental health sector and suggests a role for researchers to reduce the inappropriate use of race in psychiatric practice while limiting its detrimental impact on care nationwide.

This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.

This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.

Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).

Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.

Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.

While leaders and supervisors are responsible for ensuring a professional and respectful work environment, some may display disruptive and unprofessional behavior themselves. This systematic and critical review of abusive supervision research identified four major challenges facing the field, explaining how each challenge has limited past research, and offers recommendations for future research.

Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.

There has been some controversy around the term ‘second victim.’ Based on qualitative interviews with representatives of medical training organizations and legal professionals in Ireland, this study found that the use of term ‘second victim’ can be seen as insensitive to the patient and can erode the professional identity of the healthcare provider.

Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.

Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.

Patient safety incidents occurring in prehospital care settings are gaining increasing attention. This systematic review including both peer-reviewed studies and grey literature found that the incidence rate of prehospital patient safety incidents is similar to hospital rates. The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients occurring in prehospital care; approximately 15% of these incidents resulted in patient harm. The authors discuss methodological challenges to preshopital care research and make recommendations for future studies.

Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses may help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.

Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.

The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.