Becoming a high-reliability organization (HRO) to improve patient safety is a goal of the Veterans Heath Administration (VHA). This commentary describes the VHA's implementation strategy and progress since 2019 at the patient, employee, and organizational levels. The three pillars of the VHA's HRO strategy are leadership commitment, a culture of safety, and continuous process improvement. Challenges associated with the COVID-19 pandemic are also discussed.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

Staffing and nursing time at the bedside play a role in missed nursing care. This study focused on the role of COVID-19 on staffing and nursing time at the bedside and, therefore, on missed nursing care in labor and delivery units. During a peak of the pandemic, this study of obstetrics nurses found perceptions of nursing time at the bedside and adequate staffing played a significant role in missed nursing care.

Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and an electronic health record form was developed to document and track HAPI. A root cause analysis was completed for each HAPI to identify trends and implement improvements.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.

Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

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.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

Verbal or physical violence towards healthcare workers can result in harm of both staff and patients. Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED) at one large academic health system, the authors explored nursing perspectives on how EHR-based behavioral flags – used to identify incidents of workplace violence – can promote clinician safety. Participants identified benefits of the flags as well as concerns (e.g., introduction of bias, potential damage to the patient-clinician relationship), highlighted necessary system improvements, and how related challenges in the ED (e.g., unmet mental health needs of patients, COVID-19-related burnout) can contribute to workplace violence.

Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.