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Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.

Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.

After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.

Clinicians sometimes need to address errors committed by other providers, who may or may not be part of their own organization. This study used simulated cases to explore patient preferences for error disclosure when the disclosing provider was not involved in the error. Patients strongly preferred that these errors be treated similarly to other errors, asking for full disclosure whenever possible. A review article and a WebM&M commentary discuss frameworks for providers to use when disclosing errors committed by another clinician.

Although disclosure and apology for mistakes in medical care are recommended, less is known about use of such approaches for overarching system failures. This commentary explores the use of apology in global health programs. The authors use case studies to highlight ethical, legal, and human rights principles that can be challenged when intervention design and implementation result in unintentional harm.