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Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.

The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

Patient-centered care ensures that patient values, needs and preferences are respected; however, some patient populations, such as older adults with dementia, may require assistance. This article describes iatrogenic harm resulting from well-intended assistance in residential long-term care.

Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.

New graduate registered nurses (NGRNs) frequently experience a knowledge-practice gap during their transition to practice. This article suggests that the gap has widened, as COVID-19 restrictions impacted pre-licensure nurses’ education, clinical training, testing, and licensure. Recommendations for improving the transition to practice include innovative academic-clinical partnerships.

While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.

Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.

In dual process thinking, Type 1 decisions are made rapidly, but can result in diagnostic error. Type 2 processing is slower and more deliberate, and typically where novice clinicians begin practice. This article proposes adaptive expertise to improve novices’ processing. Incorporating six strategies (rationality, critical thinking, metacognitive processes, lateral thinking, medical humanities, distributed cognition) in medical education may improve learners’ processing and reduce diagnostic errors.

Transgender and gender-diverse may experience poor quality of healthcare due to stigma and discrimination. This systematic review of qualitative studies found that stigma experienced among transgender and gender-diverse patients occurs at the individual (e.g., internalized stigma, marginalization), interpersonal (e.g., verbal abuse from healthcare providers, withholding of care), and structural levels (e.g., gender norms, power imbalances).

Cross-sectional research has suggested many physicians experience burnout which can negatively impact patient safety. This longitudinal study evaluated the effect of workload (collected via electronic health record audit) on burnout and medication errors (i.e., retract-and-reorder [RAR] events) of internal medicine interns. Higher levels of workload were associated with burnout; there was no statistically significant association between burnout and RAR events.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.