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Falk A-C, Nymark C, Göransson KE, et al. Intensive Crit Care Nurs. 2022:103276.
Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.
Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2022;18:210-224.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56:885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.
von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. J Nurs Manag. 2021;29:2343-2352.
Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.
Longhini J, Papastavrou E, Efstathiou G, et al. J Nurs Manag. 2021;29:572-583.
This international qualitative study explored strategies employed by nurse managers and directors to prevent missed nursing care. Most strategies, including staffing ratios, communication, and empowering nurse leaders, required complex interventions at the system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and hospital level.
Lurvey LD, Fassett MJ, Kanter MH. Jt Comm J Qual Patient Saf. 2021;47:288-295.
High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.

Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.
Ihlebæk HM. Int J Nurs Stud. 2020;109:103636.
Using ethnographic methods, this study explored the impact of ‘silent report’ (computer-mediated handover) on nurses’ cognitive work and communication. The authors summarize four emerging themes, which highlight and characterize the importance of oral communication to ensure accurate and useful handovers.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
Nygaard AM, Selnes Haugdahl H, Støre Brinchmann B, et al. J Clin Nurs. 2020;29:3822-3834.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes.  This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.
Leuridan G. Safety Sci. 2020;129:104839.
The author defines ‘work debate spaces’ as organizational spaces that serve as a vehicle for organizational learning, practice changes, and performance improvement. This article discusses the role of formal and informal ‘work debate spaces’ in establishing a culture of safety in critical care settings. Examples of formal and informal spaces include mortality and morbidity (M&M) meetings (formal) and handoffs between shifts (informal).
Lindblad M, Unbeck M, Nilsson L, et al. BMC Health Serv Res. 2020;20:289.
This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.