This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

The operating room is a high-risk environment influenced by culture, teamwork, and task complexity. This review provides an overview of patient safety challenges in the operating room and highlights key approaches for improvement such as system engineering, collaboration, and checklists.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

The TeamSTEPPS® program was developed to support effective communication and teamwork in health care. The curriculum offers training for participants to implement TeamSTEPPS® in their organizations. The 3.0 version of the material has an increased focus on patient engagement and a broader range of clinical, administrative and leadership roles. The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick reference to keyTeamSTEPPS® concepts and tools, and new patient videos.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The latest PSRP report discusses the Commission's collaborative efforts in 2022 to implement changes aligned with the Safer Together report. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.