Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Patients with rare diseases present diagnostic challenges. This article introduces the potential for improvements in diagnosis that telemedicine brings to the process through enabling access to appropriate expertise previously limited by geography. 

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman. 

Patients with cancer and other chronic disorder treatment needs have been negatively affected by the restructuring of services to reduce the spread of the coronavirus. This story discusses company strategies to prepare to virtually support patients with a range of conditions. The author shares communication and support tactics to keep patients safe until they can get their appointments.

System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.

Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.

Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.

Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.

Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.

Preventing readmissions after hospital discharge is a national policy priority. This newspaper article discusses how poor communication between hospital-based and outpatient physicians, lack of involvement of the frontline care team in the discharge process, and production pressures can diminish the safety of discharge. The piece also describes strategies to enhance transitions and reduce readmission rates.

Patient engagement is increasingly recognized as a key strategy to enhance safety in health care. This article describes how failure to communicate effectively with patients can reduce safety and outlines tactics to involve patients and families in care transitions.

Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.