Letter From the Editor

Abstract

I am excited to bring you the June issue of Patient Safety!

You have probably heard time and again that involving families in patient care is the right thing to do. But how does family/visitor involvement impact patient safety? Can it make patient safety worse? Patient Safety Analyst Christine Sanchez and colleagues looked for answers.

Their study affirmed that visitors play an important role in improving patient safety, but there are times when their actions may be detrimental to the patient. Find out how you can harness the good while mitigating the risks involved with patient visitors in your facility.

This issue also features the Patient Safety Authority’s much-anticipated annual data reports. Drawing information from the largest database of its kind in the United States, Shawn Kepner and Rebecca Jones show you precisely what was reported across the Commonwealth of Pennsylvania in 2021. From the most common type of event in hospitals to healthcare-associated infections affecting nursing home residents, their concise analyses make the most complex information easy to understand.

Medication management, from prescribing to administering, is one of the most precarious processes when it comes to our youngest patients. Dose calculation errors pose some of the greatest risk because of their prevalence—and potentially catastrophic outcomes in the pediatric population. A team from the MedStar Health Research Institute analyzed 326 pediatric dose calculation patient safety events and found that 81.6% of them might have been prevented with optimal technology.

From our cover, Dr. Mehool Patel shares what happened when a technical issue between two electronic health record systems resulted in a communication breakdown between providers, affecting 42,251 patients. This paper describes the systematic approach taken to analyze the event and identify potential harm to individual patients.

Additional manuscripts in this issue include a study by a team at Jefferson Health that describes how a simple checklist can improve awareness and compliance with established protocols, and a root cause analysis conducted by Dr. Cecilia Bigio et al. related to an adverse event that occurred in a Portuguese pediatric hospital.

This journal was designed for authors to freely share the important work they do to improve patient safety, and for readers to freely receive the information, strategies, and lessons learned to make the care they provide and receive safer. Thank you to our authors, reviewers, staff, editorial board, and readers for your continued contributions.

Stay safe and stay well!