Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.

Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.

Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.

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.

Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  

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.

The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.

Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  

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.  

This study used semi-structured interviews with nurses to explore their experiences with organizational learning. Thematic analyses revealed that organizational learning was more effective when closely aligned with the Organisational Learning in Hospitals model and suggests that health system leadership and nurse managers play a central role in organizational learning.

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.

Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.