An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.

Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur at levels similar to hospitals. This study explored adverse events related to home mechanical ventilation (HMV), in order to categorize causes and recommend solutions. Interventions for nurses (e.g., checklists) and manufacturers (e.g., alarm design) may improve HMV.

Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Vital signs remain a mainstay of monitoring for deterioration, and early identification of and rapid response to clinical deterioration is critical to preventing patient harm. This observational study used an automated technique to characterize vital sign measurement for nearly 50,000 intensive care unit stays. Investigators found that omission of vital sign recording occurred more than one third of the time. The analysis identified logically inconsistent blood pressure measurements, which suggested data-entry error. The data included a significant proportion of unusual, outlier vital sign values. Taken together, these results demonstrate important inaccuracy in vital sign documentation in the intensive care unit. The authors recommend seeking alternatives to hourly vital sign monitoring in order to optimize safety. A previous WebM&M commmentary discussed challenges in monitoring vital signs.

Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.

In this study of a single neonatal unit, point-of-care testing resulted in many more quality errors compared to central laboratory testing. More than 45% of the point-of-care tests lacked appropriate patient identification, a problem the authors hope to fix by changing to a barcoding system in their hospital.

Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.

The recent death of comedienne Joan Rivers, which followed a cardiac arrest during a routine throat procedure, has brought national attention to the potential safety hazards of office-based procedural anesthesia. This retrospective study examined adverse events associated with moderate procedural sedation performed outside of the operating room at a tertiary medical center. Adverse events were relatively rare, with only 52 safety incidents identified out of more than 140,000 cases over an 8-year period. The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged bag-mask ventilation. Women were found to be at particularly increased risk for adverse events including oversedation and hypotension. These findings suggest that a combination of patient and procedural characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring and staffing for patients likely to experience sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild West" of patient safety.