Care integration —the linking of care across primary, secondary, social, community, and mental health—can improve care for patients with chronic conditions. In this review, 24 studies of integrated care were included. Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home or across settings (e.g., hospital and primary care). The authors recommend future research focus on safety targets beyond falls and medication safety and report on outcomes.

Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.

Patient safety incident reporting is an important tool for characterizing events and identifying opportunities for patient safety improvements. This longitudinal study describes chiropractic safety incidents reported to an online reporting and learning system used in the UK, Canada, and Australia. One-quarter of incidents related to post-treatment distress or pain. Documented areas for learning and safety improvement included reducing patient falls, improving continuity of care, and improving recognition of serious pathology requiring escalation to other care providers.

Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.

Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.

Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.

Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.

Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.

This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.

Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.

Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.

Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.

High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.

Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.