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Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.

The usability of health information technology, such as electronic health records (EHR), continues to present a patient safety risk. This commentary describes usability issues such as nurses’ cognitive burden (e.g., non-intuitive EHR design) and system malfunctions (e.g., clinical decision support alerts fire for wrong patients). The author recommends that research and resources should focus on simplifying, integrating, and automating data collection.

Ensuring that healthcare workers feel comfortable speaking up about concerns – also known as psychological safety – is an essential component of patient safety. This concept analysis identified five attributes of psychological safety in healthcare settings – (1) perceptions of consequences related to taking interpersonal risks; (2) strong interpersonal relationships; (3) group-level phenomenon; (4) safe work environments supporting interpersonal risks and (5) non-punitive culture.

Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.

Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.  

The COVID-19 pandemic dramatically changed healthcare delivery and has raised new patient safety concerns. This retrospective study investigated the impact of the first wave of COVID-19 on patient safety incidents at one health system in Ontario, Canada. Researchers identified significant changes in the composition of events – such as increase in falls – which may reflect changes in care processes (e.g., reduced patient surveillance, use of personal protective equipment) occurring during that time.

Simulation training is a valuable tool to improve patient care. In this study, researchers explored latent safety threats identified during multidisciplinary simulation-based team training delivered to 21 hospitals in New Zealand. Common latent threats were related to knowledge and skills, team factors, task- or technology-related factors, and work environment threats.

Implicit biases among healthcare providers can contribute to poor decision-making and impede safe, effective care. This systematic review assessed the efficacy of interventions designed to reduce explicit and implicit biases among healthcare providers and students. The researchers found that many interventions can increase awareness of implicit biases among participants, but no intervention achieved sustained reduction of implicit biases. The authors propose a conceptual model illustrating interactions between structural determinants (e.g., social determinants of health, language concordance, biased learning environments) and provider implicit bias.

The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.

Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.

Labor and delivery units are high-risk care environments. Based on a retrospective review of obstetrical adverse events occurring at one German hospital in 2018, researchers created a matrix of preventable factors contributing to adverse events. Six categories of preventable events were identified (peripartum therapy delay; diagnostic error; inadequate maternal birth position; organizational errors; inadequate fetal monitoring; medication error) and 19 associated risk factors, including language barriers, missed diagnosis of a preexisting condition, and on-call duty.

Adverse drug events (ADEs) are an important cause of hospitalizations in older adults. Based on data from the OPERAM trial, this study explored the accuracy of triggers for identifying medication-related hospital admissions in older adults. Triggers were related to diagnoses (e.g., falls, bleeding, thromboembolic events), laboratory values (e.g., hypo- or hyperglycemia) and other factors (e.g., mention of an ADE in the patient record, abrupt medication discontinuation). Among 1,235 included hospitalizations, 58% cases had at least one trigger; medication-related admissions were adjudicated in 72% of these cases.

Reporting of near misses and adverse events can provide a foundation for learning from error. This quality improvement project surveyed radiation oncology staff in two local health districts to assess understanding and use of incident learning systems, barriers to reporting or needs for process change, and perception of departmental safety culture. System processes (e.g., takes too long) were identified as barriers to reporting more frequently than safety culture (e.g., fear of negative action towards self or others).