Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research, through findings on clinician bias, technological tools, current initiatives directed at improving health equity, and in clinical areas such as obstetrics.

Throughout 2023, the importance of communication during transitions of care was a recurrent theme among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses strategies for effective communication during transitions of care, spanning interactions among healthcare professionals, across organizations, and with patients, families, and caregivers.

Throughout 2023, the importance patient safety culture and workforce safety culture were recurrent themes among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses concepts of psychological safety and employee voice, individual and team factors, and leadership and organizational factors related to safety culture.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.¹ However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors. As a testament to the significance of this topic in recent years, several government agencies [(e.g. the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid services (CMS)] have developed resources to help healthcare organizations integrate technology, such as the Safety Assurance Factors for EHR Resilience (SAFER) guides developed by the Office of the National Coordinator for Health Information Technology (ONC).^2,3,4 However, there is some evidence that these resources have not been widely used.5 Recently, the Centers for Medicare & Medicaid Services (CMS) started requiring hospitals to use the SAFER guides as part of the FY 2022 Hospital Inpatient Prospective Payment Systems (IPPS), which should raise awareness and uptake of the guides.⁶

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

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.