Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.

This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.

This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).

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.  

The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.

This study explored the relationship between nursing workload and turbulence, or unexpected work complexities and activities. Using responses from a survey of members of the American Association of Critical-Care Nurses, the authors identified several types of turbulence, such as changes in acuity, interruptions, distractions, lack of training, and administrative demands. They found that turbulence was strongly correlated with patient safety risk whereas workload had the weakest association. Acknowledging the difference between nursing workload and turbulence can enhance our ability to target resources in nursing care and improve patient outcomes.  

Research has suggested that health care providers’ emotions may impact patient safety. These authors conducted 86 semi-structured interviews with emergency department (ED) nurses and physicians to better understand their emotional triggers, beliefs about emotional influences on patient safety, and emotional management strategies. Patients often triggered both positive and negative emotions; hospital- or systems-level factors primarily triggered negative emotions. Providers were aware that negative emotions can adversely impact clinical decision-making and place patients at risk; future research should explore whether emotional regulation strategies can mitigate these safety risks.

This commentary explores two scientific cultures in modern medicine. A ‘traditional culture’ leaves error control up to individuals and groups of healthcare practitioners; the author describes how this culture leads to an overconfidence among practitioners about personal abilities to reduce errors. In contrast, a ‘modern scientific culture’ considers errors as inevitable and pervasive throughout medicine and beyond individuals or groups to control. The author describes the competing priorities of these cultures, and suggests that error control efforts in medicine will be more successful if there is a paradigm shift towards a more ‘modern’ attitude.