Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  

Incident reporting systems may be underutilized by medical trainees. This article describes a brief, interactive simulation activity to improve identification and reporting of patient safety hazards among medical students and interns.

Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.

This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  

Although disclosure and apology for mistakes in medical care are recommended, less is known about use of such approaches for overarching system failures. This commentary explores the use of apology in global health programs. The authors use case studies to highlight ethical, legal, and human rights principles that can be challenged when intervention design and implementation result in unintentional harm.

Using semistructured interviews with experienced oncology nurses and doctors, this study found that staff were willing to speak up regarding medication safety, but they were not as comfortable voicing concerns related to hygiene and safety rule violations. In these circumstances, staff frequently relied on non-verbal gestures, such as handing the physician gloves.

Conceptually analogous to failure mode and effect analysis, the Bow-Tie method is used to prospectively detect safety hazards. In this study, the Bow-Tie method was used to identify latent safety hazards in intrahospital transport, risk factors for unintentional extubation, and contributors to poor interdisciplinary communication.

This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.