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Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  

Quality improvement and patient safety (QIPS) programs are intended to increase patient safety competency during graduate medical education. This article describes the development and implementation of a consortium aimed to improve QIPS education at a large academic health center. Primary goals of the consortium include to (1) expand learner-driven, interprofessional opportunities, (2) leverage simulation training, and (3) engage and collaborate with community stakeholders.  

Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  

Health systems are undertaking various approaches to reduce nosocomial transmission of COVID-19. This study found that psychiatric departments may be more susceptible to hospital-acquired COVID-19 due to treating high-risk populations, lower adherence to infection prevention policies, inadequate environmental changes, and organizational policy challenges.   

The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery. 

This systematic review is an update of prior research characterizing the evidence base on team effectiveness in healthcare organizations. The review analyzed 297 publications focused on three types of interventions: (1) training, including crew resource management, TeamSTEPPS and simulations, (2) tools, including SBARs and checklists, and (3) organizational (re)designs, which involves intervening in structures which lead to improved team functioning (such as changing the physical environment or altering roles/responsibilities). The authors found that existing evidence base is limited to certain interventions, settings (primarily acute care), and outcomes (primarily non-technical skills). The authors call for more longitudinal research, particularly examining team functioning outside the hospital setting.

Surgical overlap is a longstanding practice, and reports suggest a link to postoperative complications and patient safety. This study measured the impact of overlap on patient outcomes among patients undergoing cardiac surgical interventions over a two-year period and found that overlap did not predict mortality, readmission, reoperation or emergency department visits at 30- or 90-days post-discharge, compared to patients without surgical overlap.

Care transitions between hospitals and community settings have been identified as a source of negative patient safety outcomes, such as medication errors or other adverse events. This systematic review focused on transitions of care within hospitals (such as within the same unit or between units) and found two studies demonstrating that the risk of adverse events - such as medication errors, infections or falls - increased as patients experienced three or more transfers. A prior PSNet WebM&M also discussed medication errors that can arise during transitions between hospital units.

Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.

This study looked at the impact of two different models of delivering care by nurses, team versus total care, on quality of care and adverse events. The authors found that the team nursing model reported higher frequency of adverse events when there were licensed practical nurses on the team.

This Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that provide care to pediatric patients. The authors identify risks and provide recommendations to ensure safe care of children including optimizing technology, utilizing external resources, and ensuring a pediatric pharmacist is in place.

New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.