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Work conditions can impact clinician satisfaction and the quality and safety of the care they provide. This study sought to identify the combination of systems features (team dynamics, provider-perceived safety culture, patient care coordination) that positively impact work satisfaction in primary care practices. Results showed a strong culture of safety combined with more effective team dynamics were sufficient to lead to improved work satisfaction.

Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.

Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..

Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.

Hospital-acquired functional decline can lead to poor health outcomes for frail older adults. This multicenter, prospective cohort study set in Japan assessed the effect of hospital-acquired function decline on post-discharge outcomes among older adults who had undergone cardiac surgery. The study observed poor prognostic outcomes in one-third of patients. Hospital-acquired functional decline was an independent predictor of poor prognosis. The authors encourage hospitals to develop and implement approaches to preventing functional decline in older adults.

Effective team communication is a cornerstone to ensuring safe patient care, particularly during stressful situations. To evaluate baseline team communication behavior, clinicians at this institution participated in interprofessional video-recorded simulations of a code response and debriefing, followed by standardized evaluations by external reviewers. Evaluations indicate variable performance on different team communication behaviors (highest for escalating care and thinking out loud, lowest for verbally establishing leadership). The authors suggest that assessing baseline communication behaviors can guide future interventions to promote and improve quality and patient safety.

Medication reconciliation is a widely used strategy to reduce medication adverse events in acute care; however, its use in primary care is less studied. The aims of this study were to identify behaviors indicative of obtaining a best possible medication history, barriers to medication reconciliation, and what improvements could be made. Numerous inconsistencies related to  medication reconciliation were identified (i.e. standardization, knowledge, importance, and inadequate integration).

Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.

Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.  

The COVID-19 pandemic dramatically changed healthcare delivery and has raised new patient safety concerns. This retrospective study investigated the impact of the first wave of COVID-19 on patient safety incidents at one health system in Ontario, Canada. Researchers identified significant changes in the composition of events – such as increase in falls – which may reflect changes in care processes (e.g., reduced patient surveillance, use of personal protective equipment) occurring during that time.

Appropriate levels of nurse staffing have been shown to improve patient outcomes. This national study explored the effect of nurse staffing on clinical quality, nurse experience, and nurse engagement. Consistent with earlier research, nurse staffing was associated with improved clinical outcomes.