Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.

Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.

Effective teamwork training for surgical teams can improve post-operative mortality rates. This review aimed to evaluate the effect of a dedicated surgical team (e.g., a team who received technical and/or communication teamwork training) on clinical and performance outcomes. Implementation of dedicated surgical teams resulted in improved mortality rates, but no difference in readmission rates or length of stay.

Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.

Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).

Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).

Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

Many types of interventions, such as education, technology, and simulations, have been used to reduce medication errors in the intensive care setting. This review identified 11 studies representing six intervention types; three of the six types showed improvement (prefilled syringe, nurses’ education program, and the protocolized program logic form) while the other three demonstrated mixed results.

Newborn falls or drops are receiving increasing attention as a patient safety issue. This article discusses a quality improvement initiative launched at one hospital aimed to decrease newborn falls through new parent education materials, a nursing risk assessment tool, and standardized reporting system. Three years after implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries over the three-year period.

Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.

Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.

Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.

Increases in clinician workload can contribute to burnout. This study explored seasonal variation in workload in an orthopedic trauma service at one Level 1 trauma center. Findings indicate that workload was highest in the summer months and correlated with resident sleepiness scores. The study team also found that patient safety events were highest during the summer, but these were not correlated with increased workload.