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.  

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.

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 review expands upon previous work evaluating implementation strategies for high-reliability organizations. Review findings indicate that health care system adoption of high-reliability principles is associated with improved outcomes, but the level of evidence is low. Future research should include concurrent control groups to minimize bias and focus on whether certain high-reliability frameworks, metrics, or intervention components lead to greater improvements.  

Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.

Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.  

This article discusses the tension between evidence generation from observational studies and rigorous randomized controlled trials to treat COVID-19 and important safety considerations, such as use of unproven therapies.

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 study found that two early warning scores – the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) – can predict patients at risk of deterioration and who will need to be seen by a physician overnight. The authors conclude that use of such early warning scores may be useful for improving handoffs and resource allocation for overnight care.

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 of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.

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.  

As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.

Prospective observational study examined whether nursing complexity level predicts adverse event risk among patients transferred from the ICU to the discharge ward. In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity predated risk of adverse events (AEs); patients who exceeded a predetermined complexity threshold were at 3-times greater risk of AEs.

The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.

Care for older hospitalized patients can be complex due to multimorbidities and polypharmacy. This review found that restraint use and limiting mobility to prevent falls can result in functional losses in geriatric patients. The authors suggest multidisciplinary approaches to shifting the goals of nursing care to focus on preserving and restoring function in older patients.

Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.