Defining and measuring patient safety is an ongoing challenge. This systematic review explored international approaches to defining serious reportable patient safety incidents. Findings indicate wide variation in terminology and reporting systems among countries which may contribute to missed opportunities for learning. Serious reportable patient safety events were commonly defined as being largely preventable; having the potential for significant learning; causing serious harm or having the potential to cause serious harm; measurable and feasible to report, and; running the risk of recurrence.

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.

This study investigated the relationship between hospital staff perceived sociotemporal structures, safety attitudes, and work-related well-being. The researchers identified that hospital “pace” plays a central role in understanding that relationship, and a focus on “pace” can significantly improve staff well-being and safety attitudes.

Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.

Allowing patients to access their own ambulatory clinical health record has benefits such as identification of errors and increased trust. This study focused on risks and benefits of patient access to mental health care records. Experts suggested the benefits would be similar to those seen in primary care, such as increased patient engagement, with the potential additional benefit of reduced stigmatization.

Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.

Simulation training is often used to develop clinical and nontechnical skills as part of nursing education.  This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.

Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 

Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality.  Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).

Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.

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.

Clinicians can experience adverse psychological consequences after making a mistake. This survey of 1,167 nurses found that social capital (both alone and in combination with psychological capital) has a significant impact on the severity of these adverse psychological outcomes.

Patient reports of patient safety incidents are one method to detect safety hazards. This telephone survey of German citizens found that patients frequently report patient safety incidents back to their general practitioner or specialist and these incidents can lead to loss of trust in the physician.

This article summarizes the principles of high reliability organizations (HROs) and how one healthcare organization sought to become an HRO by emphasizing a culture of safety and the learning healthcare system. The authors discuss how the principles of high-reliability were successfully leveraged during the COVID-19 pandemic.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.