Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.

Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.

Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

Many labor and delivery wards have implemented continuous fetal and maternal monitoring to improve patient safety, but this continuous monitoring may also have unintended consequences, such as alarm fatigue. This labor and delivery ward sought to decrease the overuse of monitoring, and related false or missed alarms, on low-risk obstetrical patients. Through the development and implementation of a vital sign guideline assessment, the rate of alarms was decreased with no increase in maternal complications.

Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.

The effective use of resources through stewardship initiatives can support error reduction through focusing actions of care. This commentary discusses how diagnostic stewardship can enhance diagnostic testing behaviors across the diagnostic process.