Direct oral anticoagulant (DOAC) dosing is complex and can lead to medication errors. This analysis of 15,730 incident reports involving DOACs reported in the United Kingdom between 2017 and 2019 found that the majority (87.6%) were due to active failures and 2.2% resulted in moderate/severe harm or death. This PSNet WebM&M commentary discusses approaches to improving safety when prescribing DOACs.

Emergency medical services (EMS) personnel encounter unique safety challenges when delivering patient care. Using focus groups and individual interviews with EMS medical directors and managers in Finland, this qualitative study explored perceptions around patient collaboration to improve safety in EMS. Participants agreed that patient safety is an organizational responsibility and management should provide EMS patients with opportunities to speak up as well as address barriers to voicing concerns.

Preventing inpatient falls is a patient safety target. This study used one health system’s incident reporting tool in the United Kingdom to ascertain the incidence and characteristics of inpatient falls among patients under 1:1 or “cohorting” supervision. Findings indicate that nearly one in five falls occurred while the patient was under enhanced supervision and most commonly occurred in the patient’s bathroom or bedside.

Remote patient monitoring (RPM) allows patients to remain in their homes while still receiving disease management. This study involved patients with chronic conditions who were receiving RPM and clinicians (nurses and physicians) who were providing RPM. Clinicians described the importance of knowing patients' level of health literacy and ensuring they understand when someone is reviewing their remote data (e.g., not on weekends). Patients reported feeling more confident, knowing someone was checking on them weekly. Overall, both groups had positive perceptions of patient safety.

The World Health Organization's (WHO) Surgical Safety Checklist (SSC) has resulted in improved surgical outcomes; however, use of the checklist varies. In this study, surgical personnel (surgeons, anesthesiologists, nurse anesthetists, surgical nurses, and assistant nurses) were surveyed about use of the SCC in their hospital, including who was responsible for ensuring its use. Although most groups reported it was not clear who was responsible for implementing the SSC prior to surgery, they believed it was the assistant nurse.

Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.

The Measurement and Monitoring of Safety Framework (MMSF) draws on principles of high-reliability to increase patient safety at the organizational level. This commentary describes the Canadian Learning Collaborative’s experience implementing MMSF and highlights several key elements for successful implementation.

Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.

Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.

A simulation study in 2017 showed anesthesia residents performed worse when sleep-deprived after working a night shift. In this quantitative study of more than 5,000 European anesthesiologists, participants reported that working night shifts reduced their quality of life and put their patients at risk. Few reported institutional support (e.g., training, fatigue monitoring) for night shift workers. Importantly, this study reports on perceived risk to patients, not actual patient risk.

While medical trainees and residents agree that disclosing errors to patients is important, they also perceive barriers to doing so. In this study, surgical trainees described factors influencing their decisions not to disclose errors despite their intention to do so. Even with formal communication trainings throughout the program, participants reported a lack of sufficient education in error disclosure. Workplace culture and role-modelling influenced their own disclosure practices both positively and negatively.

The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.

Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.

Children are particularly vulnerable to medication errors. Weight- and age-based dosing, different medication formulations, and miscommunication with parents and caregivers contribute to errors. Data-driven education and peer feedback have been noted as effective strategies to reduce prescribing errors.