Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.

Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.

The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   

In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.

This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.

This secondary analysis combined survey data from individual nurses with hospital safety culture data and found that both individual characteristics such as education level and hospital characteristics such as safety culture were associated with risks of medication administration errors and falls. The authors conclude that improving safety culture should be a high priority.

Improper injection practices associated with point-of-care testing and treatment can contribute to the spread of health care–associated infections. This position paper outlines how clinicians and infection preventionists can reduce unsafe behaviors with surveillance, oversight, enforcement, individual skills development, and professional accountability.

This study reports on an initiative to encourage student nurses to voluntarily report errors and near misses encountered during ambulatory care rotations.

This review identifies training and interventions that nursing management can implement to improve patient safety.

This study found that trained undergraduate student volunteers were able to complete important medication reviews for patients as part of an in-home outreach program.

This study surveyed more than 5000 providers who reported elements of unsafe injection practices, including use of single-dose/use vials for more than one patient, and reuse of syringes.