Emergency department triage nurses use their knowledge, experience, expertise, and critical thinking skills to prioritize patients by severity, ensuring the sickest patients are seen first. This study sought to identify cognitive biases that may negatively impact nurses' triage decision making. In a scenario describing a patient at Emergency Severity Index (ESI) level 1, the highest level, only 51% of nurses selected the cognitively unbiased triage response.

The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.

Improving clinical reasoning is an important component of medical education. Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified 15 priority conditions that can be used to improve clinical reasoning education for general practitioners. The conditions represent common (e.g., eye infection), complex common (e.g., renal insufficiency, cardiovascular disease, cancer), and complex rare conditions (e.g., ectopic pregnancy) and often demonstrate atypical presentations or complex contextual factors important for diagnostic reasoning.

In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.

Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones.  Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.

Accurate and complete clinical documentation is essential to high quality, safe healthcare. In this simulation study, senior medical residents responded to pages regarding sepsis or atrial fibrillation (phone encounter) and documented a brief note regarding the encounter afterwards (documentation encounter). The study found that written documentation following a clinical encounter included more important clinical information (e.g., ordering blood cultures for sepsis, placing a patient on telemetry) compared to what was discussed during the phone encounter.

True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.

Misleading or unclear abbreviations can cause communication errors and threaten patient safety. This article highlights how lessons learned regarding abbreviations in aviation can apply to healthcare to avoid abbreviation-related medical errors, such as prescribing errors.

The surgical time out is an effective strategy to reduce errors and improve team communication but full team participation remains a challenge. This article describes a Plan, Do, Study, Act project of developing and implementing a white board time out checklist to encourage all operating room personnel to participate. A significant increase in the number of completed time out items was seen after implementation.

Leadership style can dramatically impact the culture of safety. This analysis of video-recorded endovascular procedures found that surgeons’ transformational leadership style (e.g., motivation/enthusiasm, individual consideration, emphasis on the collective mission) positively impacts team behaviors such as speaking up behaviors and knowledge sharing.

In-hospital cardiac arrests (IHCAs) are complex clinical scenarios requiring effective communication and teamwork. This study assessed the impact of a bundled, multicomponent intervention to empower telemetry technicians and improve communication between telemetry technicians and other clinicians during in-hospital cardiac arrest. After bundle implementation, researchers observed improvements in IHCA survival.

Artificial intelligence (AI) has become a useful tool to support radiologists in diagnostic imaging. In this study, discordant findings between the radiologist and AI (negative by radiologist report, positive by AI report, with unviewed AI decision support system output) triggered an automatic manual review of the diagnostic images. More than 111,000 CT studies were analyzed, with 46 triggering the automatic review; of those, 26 (0.02%) were true positives (i.e., missed diagnosis by radiologist but identified by AI).

Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.