All Content

The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.

Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.

Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

Alert fatigue contributes to task burden and can threaten patient safety. In this study, researchers at one academic medical center found that machine learning techniques could enable intelligent filtering of medication alerts and reduce alert volume by 54%.