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Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.

Violence towards healthcare workers can result in harm for staff and patients. This article describes data collected during the first three years of a new statewide incident reporting system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals. Over the three-year period, hospitals reported between 0 and 6 incidents per staffed bed but qualitative analyses revealed variable reporting procedures among hospitals.

Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.

Patients receiving home care services are vulnerable to medication errors. Based on survey feedback from 485 home care nurses in Germany, this study found that regular medication training and use of quality assurance principles (i.e., double checking) can decrease the incidence of medication errors in home care settings.

Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.

Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.

Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.

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.

Intensive care units (ICU) are high-risk environments. Based on direct observations, these researchers identified 226 latent safety threats affecting routine care activities in pediatric ICUs. Findings indicate that threats persist regardless of whether individuals comply with or deviate from policies and protocols, suggesting the need for targeted interventions beyond reinforcing compliance.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.

Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.

Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.