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Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.

Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.

Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.

Communicating and reporting patient safety incidents relies on a robust safety culture wherein health care providers feel supported, not blamed, for errors. Using pediatric registered nurses’ responses from the 2016 and 2018 Hospital Survey on Patient Culture, researchers explored (1) associations between the communication of RNs within their teams and the frequency that they reported safety events; (2) associations between RNs’ communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs’ communication had improved from 2016 to 2018.

Patient isolation for infection prevention and control may result in unintended consequences. This systematic review examined adverse physical and psychosocial events associated with patient isolation. A meta-analysis of seven observational studies showed no adverse events related to clinical care or patient experience with isolation.

Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.

A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.

Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.

Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.

Healthcare provider implicit bias can lead to inequitable care delivery and poor patient outcomes. This review identified 42 articles about healthcare professional implicit biases, including gender, race, ethnicity, and age. Biases were detected in provider attitudes, treatment decisions, and diagnosis.

A culture of safety is a key component to successful patient safety initiatives. This systematic review explored the relationship between safety culture and safety climate dimensions and safety performance measures. The most common dimensions used to assess this relationship were the involvement of leadership, safety resources, risk management and communication, safety rules and procedures, and involvement of healthcare workers.

Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.

Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.