Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.

The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

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.

Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.

Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.  

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

Resuscitations are highly complex interventions, particularly in neonatal settings. Ineffective teamwork, poor communication, and knowledge deficits in the neonatal team can result in adverse patient outcomes. Video is one approach to mitigating these issues by providing education, practice simulations, and skill assessment in order to improve patient care.

Simulation training can enhance teamwork, identify latent problems, and contribute to improved patient outcomes. This commentary explores the value of frontline obstetric simulation to develop high reliability. The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of a successful simulation-focused organizational learning initiative.

This study describes a multidisciplinary human factors training intervention for labor and delivery care that included communication training and simulation work. Researchers found that safety culture improved compared to preintervention scores.

Guidelines play an important role in enhancing safety and reliability, but they must be rigorously evidence-based, followed, and applied. This commentary suggests that overconfidence in the guideline development process can result in reliance on recommendations that misinform practice and contribute to patient harm. As an example, the authors discuss the wide adoption of a guideline to address the cesarean delivery rate that omitted important clinical prognosticators.

This pre–post study examined the effect of team training on an emergency response team's performance in a perinatal emergency simulation. Following the training, performance in the simulation identified more latent safety threats and adherence to a safety checklist increased. The authors suggest that team training can enhance maternal safety.