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Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.

Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.

Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.

Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.

Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.

Patient characteristics such as age, comorbidities and frailty can increase risk for medication errors. This scoping review shows that studies evaluating medication harm in frail patients are largely limited the methodological quality and inadequate reporting. The authors discuss the need for more robust studies examining this relationship, including the effect of polypharmacy.

Teaching clinical reasoning to medical students is a key strategy for reducing diagnostic errors. This paper describes a new longitudinal clinical reasoning curriculum taught in a US medical school’s first and second year of medical training. Students reported high self-efficacy after completing the curriculum; however, a competency audit revealed room for improvement in including system-related aspects of care.

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.

Biases in decision support technologies precipitate racial inequities. This commentary discusses how algorithms in machine learning contribute to inaccuracies in the care of persons of color and the displaced. Legal actions to mitigate racial biases in decision making programs and implementation steps toward improvement are discussed.

Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.

Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.

In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.