Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.

Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.

This retrospective observation cohort study conducted at nine hospitals sought to determine whether discharge from the intensive care unit (ICU) directly to home affected odds of readmission within 30 days or mortality within 1 year. Overall, patients discharged from the ICU to home are younger and less ill than patients who are transferred from the ICU to the hospital ward before returning home. The proportion of patients discharged from ICU to home varied widely by site. When researchers compared patients discharged from ICU to home to patients of similar age and severity of illness upon ICU admission who were discharged home from the hospital ward, they found no differences in odds of readmission or mortality. A related commentary explores why discharges from ICU to home occur and calls for implementing care transitions best practices upon ICU discharge in order to support optimal patient outcomes and prevent readmissions.

Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.

Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.

The Joint Commission and the Accreditation Council for Graduate Medical Education have called for institutions to implement standardized handoff strategies. This systematic review found indications that checklists can improve the quality of care transitions for surgical patients, but the quality of published evidence is low.

Reorganization of a surgical morbidity and mortality conference to focus on patient safety issues using the SBAR format improved both participants' knowledge and the quality of the conference.