The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.

Patient engagement is a cornerstone of patient safety initiatives. This systematic review explored how patients and caregivers are engaged as partners in healthcare, particularly in cancer care and mental health care.

Children with complex medical conditions are particularly vulnerable to medication errors. This article describes the development and implementation of a pharmacy-led medication rounding care model for children with medical complexity wherein clinicians and pharmacists conduct weekly reviews of all patient medications using a standardized checklist.

Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

Committing errors can result in significant emotional impact on clinicians. In this study, a survey of medical assistants in Germany found that poor collaboration was a key predictor of concerns for having committed a medical error.

I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.

Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Workers who experience psychological safety in their organization are more likely to speak up about safety concerns. This study reports on how trust and psychological safety interact to increase error reporting. Results indicate that trust in leaders encouraged error reporting and psychological safety encouraged learning from mistakes.

Fatigue is a known contributor to adverse events and near misses. Researchers summarized 38 studies on the impact of fatigue on nurses’ medication administration errors (MAE) or near misses. Thirty-one studies reported that long hours, shift work, overtime, and/or poor sleep quality contributed to MAE and near miss, but results and methods of measuring fatigue were inconsistent.

The World Health Organization’s Surgical Safety Checklist has been used in populations around the globe to reduce surgical complications and improve operating room teamwork. This mixed methods study involved nearly 150 surgical nurses in Turkey. Nurses reported inconsistent use of the checklist, described barriers to its use, and offered suggestions to increase compliance with completion.

Pharmacists are increasingly involved in the emergency department (ED) medication process. This review summarizes the characteristics and impacts of interventions. The most common type of intervention is medication review/reconciliation and/or identification and resolution of medication errors. Interventions including pharmacist co-prescribing or co-charting in the ED resulted in the largest reduction in medication errors.