Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.

Older adults in long-term care settings can be vulnerable to patient safety incidents. This scoping review of 46 articles identified several gaps in the research on adverse events in long-term care and nursing home settings, including the absence of resident perspectives regarding safety and the role of interpersonal and environmental factors on the incidence of adverse events.

Physical and verbal violence against healthcare workers has been identified as a sentinel event by the Joint Commission. In this secondary analysis of survey data on workplace violence (WPV), researchers explored which attributes of patient safety culture may predict healthcare workers’ experiences of WPV and burnout. Better teamwork and staffing were among the attributes associated with lower risk of WPV.

Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.

Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.

High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.

Medication administration is a complex set of tasks completed many times per day for hospitalized patients. This study captures the turbulence of nursing work, the nursing environment, and how that impacts patient safety. The results suggest organizations should re-evaluate current attempts at improving medication administration safety and include nurses in identifying new solutions.

Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.

Organizations are encouraged to proactively identify patient safety risks and learn from failures. This article describes validity testing of systems-thinking risk assessment (Net-HARMS) to identify risks associated with patient medication administration and an accident analysis method (AcciMap) to analyze a medication administration error.

Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.

Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.

Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.

Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.

The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.

Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.

Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.