Preventing inpatient falls is a patient safety target. This study used one health system’s incident reporting tool in the United Kingdom to ascertain the incidence and characteristics of inpatient falls among patients under 1:1 or “cohorting” supervision. Findings indicate that nearly one in five falls occurred while the patient was under enhanced supervision and most commonly occurred in the patient’s bathroom or bedside.

Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.

Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.

Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.

Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.

Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

Miscommunication between healthcare providers can contribute to adverse events, but communication may be improved by strengthening psychological safety. This paper describes two studies on the association of communication, patient safety threats, and higher quality care and the mediating effect of psychological safety in obstetrical care. Results suggest psychological safety mediates the association of communication with quality of care and patient safety.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.

As more patients with COVID-19 were admitted to hospitals during the pandemic, concerns about healthcare-acquired COVID-19 and potential associated adverse events increased. In this retrospective study, 126 patients with hospital-acquired COVID-19 were moved to isolation or quarantine. Twenty-nine patients experienced one or more adverse events due to isolation or quarantine, including delayed transfer to other specialties and delayed diagnostic tests. Nosocomial COVID-19 infection was confirmed as cause of death in one patient, and a possible cause in 11 others.

Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.

Myriad factors contribute to missed nursing care including staffing, team and group norms, and teamwork. Nurses in this study described four themes that contributed to missed nursing care: teamwork in nursing wards; informal teaching and communication; influence of formal and informal leaders; and influencing factors in nurses’ work environment. Developing nurses' clinical leadership skills may improve teamwork and reduce missed care.

Quality improvement and patient safety programs implement numerous improvement projects over time, and understanding their overall success and long-term sustainability is important. This article describes the impact of improvement toolkits in the labor and delivery ward on a Norwegian hospital since the 1990s. Fourteen tools (e.g., databases, leadership seminars) and their results are described.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.

Improving care transitions is a patient safety priority. Based on interviews with 21 nurses in Sweden, this study explored nursing concerns regarding transitions of care from inpatient to home healthcare settings in rural areas. Participants cited concerns regarding care coordination, communication, and logistics.

Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.

Patient safety incident reporting is an important tool for characterizing events and identifying opportunities for patient safety improvements. This longitudinal study describes chiropractic safety incidents reported to an online reporting and learning system used in the UK, Canada, and Australia. One-quarter of incidents related to post-treatment distress or pain. Documented areas for learning and safety improvement included reducing patient falls, improving continuity of care, and improving recognition of serious pathology requiring escalation to other care providers.