Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.

Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.

The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.

Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Children with intellectual disabilities can be at higher risk for patient safety events and poor-quality care. This systematic review and thematic analysis identified several themes (e.g., distress, communication, training, and education) underscoring healthcare staff experiences in providing care for pediatric patients with intellectual disabilities. The review found that healthcare staff feel they lack necessary skills to provide care for children with intellectual disabilities and have difficulties communicating effectively with both patients and their parents.

Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.

While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.

Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.

Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.

Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..