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A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.
Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Koo A, Smith JT. Insights Imaging. 2019;10:68.
Prior research has examined what factors may influence learning from mistakes. Researchers describe their analysis of more than 600 cases discussed at educational radiology conferences over several years. They were able to identify numerous opportunities for improving learning from error, including using positive cases (e.g., near misses or difficult cases in which extra effort helped avert an error) and targeting teaching to address recurrent deficiencies.
Ryan L, Jackson D, Woods C, et al. J Adv Nurs. 2019;75:1151-1161.
This review examines international evidence on the role nurses play in implementing intentional rounds. The authors explore areas of impact, including patient satisfaction, falls, and hospital-acquired pressure ulcers, and conclude that benefits have been realized from enhanced rounding practice, but further research is needed. They offer implications for practice and highlight the role of leadership, research, and education in reducing the negative expectations of rounding initiatives.
Mohsin SU; Ibrahim Y; Levine D.
This commentary describes a project to assist medical students in understanding and reporting errors they encounter. The program included an introductory workshop, facilitated discussion about errors and the importance of reporting, and completion of a simulated error report. Results indicated that education could influence student ability and willingness to recognize and report errors during their clinical clerkship. A WebM&M commentary discussed an incident involving a medical student who failed to report an error.
After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.
Daupin J, Perrin G, Lhermitte-Pastor C, et al. J Oncol Pract. 2019;25:1195-1203.
Prior research has shown that oncology pharmacists can improve the safety of chemotherapy administration. In this prospective study, researchers found that 129 of 1346 chemotherapy prescriptions issued in a 1-month period at a single university hospital required intervention by an oncology pharmacist. The majority of such interventions were perceived as having a significant impact on patient safety.
Lloyd M, Watmough SD, O'Brien S, et al. Res Social Adm Pharm. 2018;14:936-943.
This study examined prescriber perceptions of a feedback intervention in which pharmacists told prescribers about their errors in order to improve future prescribing. Prescribers received such feedback positively, and the authors recommend systematizing prescribing feedback to enhance medication safety.
Cierniak KH; Gaunt MJ; Grissinger M.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Monahan JJ. AORN J. 2018;108:548-552.
The good catch, or near miss, can provide a key learning experience in health care practice. This article discusses the importance of organizational culture in utilizing these experiences as improvement opportunities. The author reviews strategies for nurses to engage in skill development through case review of good catches.
Palese A, Gonella S, Grassetti L, et al. Med Educ. 2018;52:1156-1166.
Incident reporting systems are widely utilized to identify safety concerns, but their effectiveness remains limited in part due to underreporting. Using data from a national survey of undergraduate nursing students in Italy, researchers found that 41.7% reported safety issues never, rarely, or sometimes.
Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.