Artificial intelligence (AI) technologies hold great promise for improving patient outcomes, reducing clinician workload, and enhancing patient engagement. However, improper design, implementation, and monitoring can introduce significant safety risks. Health care quality and safety leaders play a critical role in mitigating these risks. As AI adoption accelerates, understanding how these leaders perceive their institutions' progress in assessing and managing AI safety is critical for identifying gaps, addressing potential risks, and guiding safer clinical integration.

Some patients cannot return home after hospitalization due to temporary or permanent disabilities, leading to so-called "complex discharge." This study aims to investigate the consequences and financial implications of complex discharge, and to assess a low-cost reorganization that removed a control point in the discharge process.

Primary care clinicians are increasingly using new technologies to improve safe opioid prescribing. One of these technologies is an opioid panel dashboard, which lists patient-level information and related opioid safety measures. This paper describes our experiences of implementing dashboards in 2 different settings and how clinicians used those dashboards and their associated attitudes and perceptions.

Diagnostic errors are one of the most common and costly medical errors. Most diagnostic errors are due to provider cognitive processes and biases. With the widespread adoption of electronic health records (EHRs), and other health information technology (health IT), EHRs are now the central repository for clinical information and its design and use affect the diagnostic process and diagnostic errors. The goal of this study was to analyze patient safety event reports to determine health IT contributions to diagnostic errors. Understanding how the health IT contributes to diagnostic error will help direct improvement efforts.

The Austrian Inpatient Quality Indicators (A-IQI) are routinely measured quality and patient safety indicators derived from administrative data. A subset of these are sentinel indicators, for which even a single case of death leads to a conspicuous indicator. The purpose of this study was to assess the value of A-IQI sentinel indicators for detecting serious adverse events.

To identify scientific evidence describing the development and/or use of mobile applications to support the education of health personnel, patients, and their caregivers, focusing on hospitalized patient safety. The review was conducted on 7 electronic databases: Medline, PubMed, Cochrane, Embase, Scopus, VHL, and Web of Science, in addition to gray literature. The study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The final findings were presented regarding authorship, year of publication, country of origin, study objective, methodological design, sample and setting, mobile application development process, and main findings. Of the 1996 studies found, after removing duplicates, 1784 abstracts were evaluated. After evaluating the full texts, 12 studies were considered relevant, and discussed essential aspects of patient safety, such as drug administration and infection prevention, following the international patient safety goals. The analyzed mobile applications covered different types of content, such as serious games, educational videos, animations, and simulations. The analysis revealed a variety of approaches, including analysis, design, development, implementation, and evaluation of the apps. Content validity and the usability of mobile applications were the main aspects investigated. There has been a growing development and use of mobile applications aimed at increasing knowledge about patient safety, showing a positive trend for educating the target audience. However, there is a lack of mobile applications that display attractive features for users.

This study analyzes factors and challenges associated with adverse events reporting in Indonesian hospitals.

The operating room (OR) is a complex environment where errors significantly impact patient outcomes, and the ability of surgical teams to adapt and recover from unexpected disruptions-defined as resilience-is paramount. Frameworks offer structured approaches for analyzing resilience yet are variably applied throughout the relevant literature. This review aims to characterize how frameworks are used to study OR team resilience and examines the implications of inconsistent approaches.

Patient safety event reporting systems are essential for identifying potential risks and improving patient outcomes. However, traditional systems frequently face issues of under-reporting, particularly concerning near-miss and no-harm events, thereby limiting opportunities for organizational learning and harm prevention. This initiative used quality improvement principles to design a new reporting system at our institution to enhance safety culture.

Patient falls are an important public health issue, preventable by nurses through risk assessment and education. Here, we conduct a pilot study aimed at improving fall prevention knowledge and attitudes, and decreasing patient falls through use of a spaced-retrieval mobile app.

Missed nursing care refers to necessary nursing care activities that, due to various factors, are either not provided, partially provided, or delayed from the planned schedule. Missed nursing care (MNC) is a significant issue in nursing homes, undermining care quality and increasing the risk of adverse events and preventable hospitalizations. This systematic review aims to identify the most frequently reported MNC by nursing staff in nursing homes and the associated causes.

In creating an Agency for Healthcare Research and Quality (AHRQ) Patient Safety Learning Laboratory (PSLL), our objective has been to establish a multidisciplinary research environment focused on the safe care of pregnant women and newborns. This manuscript describes work performed under grants P30 HS023506 (obstetric focus) and R18 HS029123 (neonatal focus).

The objective of this project was to contribute to the understanding of how interruptions impact intravenous (IV) medication processes and identify areas for improvement. The specific aims were to evaluate the type, frequency, and duration of interruptions, including IV smart pump (IVSP) alerts and alarms, that nurses experience during IVSP activities.

To evaluate the impact of using a simulated teletransport application compared with ad hoc phone calls between medical control physicians (MCP) and transport teams on situational awareness and communication during neonatal interfacility transports.

Suboptimal transitional care from the hospital to home can result in poor health outcomes, increased costs, and readmissions. Telehealth-based transitional care programs have shown some improvements in readmission rates; however, it is unclear why some patients benefit while others do not. This study evaluated a connected transitional care (CTC) program that provided high-risk patients with timely post-discharge telehealth appointments conducted by a nurse practitioner. Our focus was on understanding why some patients participating in the program benefit and are not readmitted while others are readmitted.

There are gaps in understanding the experiences of children, parents, and providers during dental conscious sedation. This study aimed to capture and analyze these experiences to identify opportunities for improvement and enhance the quality and safety of pediatric dental conscious sedation.

Our objective was to develop an in-depth understanding of the barriers and facilitators for medication safety in primary care by synthesizing findings from a multiyear, multisite study of care teams, pharmacists, and patients, using Safety-I and Safety-II lenses.

We established a Patient Safety Learning Lab (AHRQ R18HS029473) to examine the sociotechnical system that drives interprofessional communication in pediatric inpatient settings in the context of evolving communication technologies, and to co-create and evaluate solutions with clinician end users. Here, we describe the use of human-centered design and system engineering processes for the Problem Analysis phase of this project.

Electronic health records (EHR)-based triggers (eTriggers) have been used to study diagnostic errors in the emergency department (ED), often with suboptimal performance. Our objective was to investigate incremental value of multi-factor machine learning (ML) approaches to improve eTrigger performance.

To explore the relationship and current status of coping styles, burnout, and hospital patient safety culture in patient suicide incidents. To examine whether nurse second victim coping styles in patient suicide incidents mediate the relationship between hospital patient safety culture and burnout.