Falls in inpatient healthcare settings are a common patient safety event. This study including 201 older inpatient adults evaluated the relationship between the Johns Hopkins Fall Risk score and patient perceptions of fall risk. Researchers found that the greater the patient’s confidence in their ability to perform a high fall-risk behavior, the lower the fall-risk score.

Nurses have reported experiencing horizontal abuse and bullying (e.g., bullying by other nurses) and perceive that workplace bullying results in errors. Using posts from the social media site Reddit, researchers sought to understand who perpetrates the abuse, types of abuse, perceived reasons, nurses’ responses, and location of abuse. Organizational strategies such as mindfulness, reshaping the culture, bystander interventions and explicit leadership support are suggested to prevent nurse co-worker abuse.

The COVID-19 pandemic dramatically changed healthcare delivery and impacted the ways healthcare teams function. Using interprofessional focus groups, this study explored the perspectives of medical intensive care unit (MICU) team members on the role of TeamSTEPPS® during the first year of the COVID-19 pandemic. Participants discussed how TeamSTEPPS® impacted teamwork and communication through shared mental models, trust, role definition, and effective briefing/debriefing and transitions of care strategies. Participants also identified several challenges to TeamSTEPPS® implementation related to the MICU environment, the ongoing pandemic, power dynamics, and patient acuity.

Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Previous research has identified errors related to use of free-text fields in the electronic health record (EHR) systems. In this study, researchers examined potential safety hazards within free-text EHR communication orders sent to or from nurses. Analyses indicated that free-text orders did include symbols and abbreviations discouraged by the Institute for Safe Medication Practices (ISMP) and that future research should explore issues stemming from workarounds and EHR design.

The effective use of resources through stewardship initiatives can support error reduction through focusing actions of care. This commentary discusses how diagnostic stewardship can enhance diagnostic testing behaviors across the diagnostic process.

Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

Patient safety incident reporting is an important tool for characterizing events and identifying opportunities for patient safety improvements. This longitudinal study describes chiropractic safety incidents reported to an online reporting and learning system used in the UK, Canada, and Australia. One-quarter of incidents related to post-treatment distress or pain. Documented areas for learning and safety improvement included reducing patient falls, improving continuity of care, and improving recognition of serious pathology requiring escalation to other care providers.

Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.

Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.

Community pharmacists play an important role in ensuring patient safety. This retrospective analysis of 18 outpatient pharmacy clinics evaluated pharmacist recommendations and impacts on medication-related safety. Researchers indicated that outpatient pharmacists were effective in resolving 82% of medication-related problems; 18% of these involved high-risk recommendations, such as medication interactions.

Transitions of care can increase risks for patient safety events. This systematic review examined the effectiveness of interventions aimed to increase patient safety during transitions of care between the hospital and home. The authors identified several interventions from previously published studies which increased patient safety and/or patient satisfaction and identified factors that contribute to effective transitions of care (i.e., nurse follow-up, pre-discharge patient education, and contact with local healthcare services).

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.