Patient Safety Authority

04/16/2026

Congratulations to Patient Safety Authority Board Chair Dr. Nirmal Joshi on being named a 2026 Health Care Hero!

Central Penn Business Journal’s annual Health Care Heroes Awards recognize excellence, promote innovation, educate on healthcare issues, and honor individuals and organizations for their significant impact on healthcare quality in Central Pennsylvania. At their awards breakfast on April 9 in Harrisburg, CPBJ honored Dr. Joshi as a Physician of the Year, in recognition of his generosity, compassionate care, and commitment to improving people’s lives.

Dr. Joshi has dedicated his life and career to helping others: providing a free health clinic and education through the Joshi Health Foundation, mentoring young physician leaders at the Pennsylvania Medical Society, and guiding PSA’s efforts to quantify and reduce medical error in the commonwealth—just a few of his many humble achievements.

Please join us in celebrating and thanking Dr. Joshi for all he does to make the world a better place!

04/15/2026

Just published: Evidence-based medicine strengthens decision-making, but contemporary care—including clinical artificial intelligence (AI)—often operates under uncertainty, heterogeneous patient contexts, and shifting performance. A common failure mode is committing too early to actions that are difficult to reverse, monitor, or repair.

Evidence-steered medicine (ESM) structures decisions as controlled microsteps: (1) a brief support check, (2) uncertainty banding that constrains action strength, (3) a low-dose action grammar prioritizing reversible micro-interventions paired with short-horizon readouts, and (4) reason-coded governance that enables auditability, learning, and rapid de-escalation/repair. The model yields measurable predictions on severe safety events, recoverability (checkpointing and de-escalation pathways), time to detection of unsafe trajectories, learning efficiency from reason-code distributions, and (in AI workflows) automation-bias and drift-trigger events.

ESM complements evidence-based medicine by making uncertainty operational: It specifies how to act safely when evidence is incomplete. The hypotheses can be evaluated using retrospective replay, prospective pilots, and stepped-wedge rollouts without replacing standard of care.

Read more for free in PATIENT SAFETY:

By Konstantin Gurbanov. Evidence-based medicine strengthens decision-making, but contemporary care—including clinical artificial intelligence (AI)—often operates under uncertainty, heterogeneous patient contexts, and shifting performance.

04/07/2026

JUST PUBLISHED:
As global Ebola virus disease (EVD) outbreaks continue to emerge, protecting healthcare workers (HCWs) remains a cornerstone of health security. Lessons from the 2014–2016 West Africa epidemic, during which two U.S. nurses were infected and 10 patients were repatriated to the United States for care, highlighted gaps in post-exposure monitoring. More recently, the 2024 case of travel-associated Lassa fever in Iowa reaffirmed the occupational risks faced by frontline clinicians: Among 180 disease contacts, 172 (96%) were healthcare-associated, and risk classification correlated with personal protective equipment lapses. These events underscore a practical reality in healthcare operations: Even a single uncertainty about an exposure can generate days to weeks of follow-up work across occupational health, infection prevention, and supervisory teams.

To strengthen preparedness, NYC Health + Hospitals developed a homegrown digital solution to monitor HCWs exposed to suspected or confirmed Ebola and other viral hemorrhagic fevers. Built in 2022, the solution automates twice-daily symptom reporting, alerting, and escalation workflows for occupational health services (OHS). A 33-day systemwide drill in 2023 evaluated usability, timeliness, and coordination. The solution achieved >95% compliance, transmitted alerts within one minute, and enabled OHS follow-up within 15 minutes. Users rated the interface intuitive and efficient. In drill use, the system also captured operationally important near miss moments, such as a missed check-in during routine monitoring, that are easy to overlook in manual tracking but often consume disproportionate staff time when discovered late.

The NYC Health + Hospitals Ebola HCW monitoring solution proved operationally feasible, user-friendly, and adaptable, demonstrating a scalable, sustainable approach to biopreparedness for health systems worldwide.

Read more for free in PATIENT SAFETY:

By Syra Madad, Andrew Vegoda & 2 more. Ebola virus disease (EVD) remains a recurring global threat, with multiple outbreaks reported in Africa since its identification in 19761 and periodic international exportation events.

03/23/2026

Just published: Ensuring patients with acute and chronic illnesses maintain appropriate nutrition is a critical component of patient care. Malnutrition in hospitalized patients is associated with adverse outcomes such as impaired wound healing, prolonged hospital stays, and poorer overall quality of care. During many disease processes, receiving adequate nutrition by eating and drinking can be challenging. When oral intake is insufficient, providing patients with nourishment (calories, macronutrients and micronutrients, and fluids) via an enteral route like a nasogastric (NG) tube or other similar mechanisms can help to improve a patient’s nutritional status, positively contributing to the patient’s care and treatment plan.

While enteral feeding offers significant benefits to patients, it is a complex process and can present patient safety risks. The amount and rate of enteral nutrition must be individualized for each patient according to their nutritional and fluid needs. Feeding infusions can be administered continuously or intermittently (e.g., bolus feeding). Common risks associated with enteral feeding include feeding intolerance, aspiration, and refeeding syndrome.

Read this article at no cost in PATIENT SAFETY:

By Christine E. Sanchez. Ensuring patients with acute and chronic illnesses maintain appropriate nutrition is a critical component of patient care. Malnutrition in hospitalized patients is associated with adverse outcomes such as impaired wound...

03/20/2026

Join us on Wednesday, March 25, from 12 to 1 p.m. EDT, for a free webinar: "Reducing Workplace Violence in Community Hospitals."

Workplace violence in healthcare is a growing national concern, and community hospitals are not immune. Mindy Dunkerley, MBA, BSN, RN, chief quality officer, and Michael Fiorina, DO, FAAP, chief medical officer, both of Independence Health System, will:

- Describe national trends and incidence rates of workplace violence in healthcare settings.

- Identify patient safety risks associated with workplace violence and explain the role of prevention programs.

- Examine the structure and key components of a health system’s workplace violence prevention program.

- Discuss the impact of workplace violence prevention initiatives on the health system’s culture of safety.

1.0 continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only.

Register now at f917e444-deeb-4b4b-a5a4-537edb853718@418e2841-0128-4dd5-9b6c-47fc5a9a1bde" rel="ugc" target="_blank">https://events.gcc.teams.microsoft.com/event/f917e444-deeb-4b4b-a5a4-537edb853718@418e2841-0128-4dd5-9b6c-47fc5a9a1bde

03/19/2026

JUST PUBLISHED! Informed consent obtained prior to a medical or surgical procedure signifies the patient’s (or their surrogate’s) permission to proceed. The process of informed consent ideally includes a two-way discussion between the patient and clinician about the procedure’s components, its individualized risks and benefits, and value alignment for the “prudent” patient. This discussion should also cover alternative options, such as other surgical procedures, medical treatments, or therapies. Additionally, the consent discussion should be in terms and language that can be understood by the patient.

While informed consent may be commonly viewed as a single pre-procedure step or obtaining a signature on a form, it is not a one-time event. Instead, informed consent is an ongoing, collaborative process between the patient and clinician. Even after consent is initially given and the procedure begins, patients retain the right to withdraw consent. This ongoing right to self-determination means that patients may elect to withdraw consent even after initiation of the procedure.

In cases where a patient attempts to withdraw consent mid-procedure, clinicians face several clinical and ethical challenges balancing patient autonomy with professional duty to avoid harm.

Read more in PATIENT SAFETY:

By Christine E. Sanchez, William D. Schweickert & 1 more. Informed consent obtained prior to a medical or surgical procedure signifies the patient’s (or their surrogate’s) permission to proceed. The process of informed consent ideally includes a two-way discussion between...

03/18/2026

Today in THE SCHOLARLY KITCHEN, Dr. Michael Bruno builds on his recent PATIENT SAFETY article and discusses the roles artificial intelligence may play in scientific publishing: https://scholarlykitchen.sspnet.org/2026/03/18/guest-post-could-ai-help-fix-peer-review-or-will-it-only-make-things-worse/ Please read, share, and comment!

Today's post asserts that peer review, which is still of vital importance to science, is clearly failing in the current age -- could AI save the day?

03/17/2026

JUST PUBLISHED! Engaging patients and families in their own care is an important way of keeping them informed and involved, leading to better treatment and outcomes. Similarly, reporting about patient safety events is vital to driving change and preventing future harm. Event reports usually originate from clinical providers such as nurses and physicians, though there continue to be many challenges around underreporting. However, patients and their caregivers also play a central role in raising safety concerns, as they often notice breakdowns in communication and procedure, and potential errors that otherwise go undetected by healthcare staff.

Patient participation in reviewing adverse events has been shown to foster learning at the organization and trust in healthcare, but patients’ ability to contribute to safety surveillance and processes is limited by lack of awareness or access to reporting systems, as well as cultural norms, insufficient buy-in at the institution, and other barriers. Moreover, there is limited evidence of whether their concerns resulted in changes or had any impact on patient safety. To better understand the state of patient- and family-initiated reporting and opportunities for improvement, this study reviewed existing literature in five major research databases for insights about mechanisms designed to allow patients and families to report safety concerns, adverse events, or near misses.

Read this article for free in PATIENT SAFETY: https://patientsafetyj.com/article/156234-patient-and-family-initiated-safety-event-reporting-a-scoping-review

Shares and likes are appreciated to help get this important information out.

By Stephanie Quon, Sarah Low & 2 more. This scoping review aimed to synthesize existing literature on the implementation, use, and impact of patient- and family-initiated safety event reporting systems across healthcare settings.

03/10/2026

It's Patient Safety Awareness Week! Annually sponsored by the Institute for Healthcare Improvement - IHI, the Center for Patient Safety has established this year's theme as "Team Up for Patient Safety."

On this occasion, we're pleased to announce the winners of the 2026 I AM Patient Safety Achievement Awards! Judges evaluated 169 nominations from 72 hospitals and facilities, and selected individuals and teams for their accomplishments in 10 award categories.

See our 2026 IAPS winners at https://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/2026-i-am-patient-safety.aspx and look forward to stories this spring about all the ways they have shown that "great care starts with strong teamwork."

Please join us in congratulating our accomplished awardees!

02/27/2026

Time's running out! The application period for our spring Master Class in writing quality improvement studies ends TONIGHT. Fill out this form and submit it by 11:59 p.m. EST:https://patientsafety.pa.gov/Documents/Writing%20Workshop/QISubmissionTemplate-Spring2026.pdf

02/26/2026

𝗧𝗵𝗶𝘀 𝗶𝘀 𝘆𝗼𝘂𝗿 𝗹𝗮𝘀𝘁 𝗰𝗵𝗮𝗻𝗰𝗲! The application period for our spring Master Class in writing quality improvement studies ends tomorrow, Feb. 27, at 11:59 p.m.

Submit your application by February 27, 2026! Our free online Master Class Writing Workshop in Quality Improvement Studies teaches you how to turn your QI project into a manuscript.

02/25/2026

New at PATIENT SAFETY: Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” This avoidable medical error continues to be significant problem in hospitals and ambulatory surgical facilities (ASFs).

Expanding on previous WSS research, the authors of this study took a novel approach: They reviewed and analyzed 644 WSS events reported in Pennsylvania from 2015 to 2024 and identified combinations of clinically related variables, such as type of facility, hospital procedure location, error type, clinician specialty, region of the body, and specific procedure. Among their findings: Most of these WSS events occurred in hospitals rather than ASFs, distributed across operating rooms, interventional radiology, and other procedural locations. The most frequently involved specialties were interventional radiology, pain management, and orthopedics.

This study represents one of the largest samples of WSS events examined in a single study. The authors have visualized their deep-dive analysis in 16 figures, tables, and supplemental appendices to help stakeholders comprehend the many combinations of variables contributing to WSS, identify these factors in their own facility, and design interventions to improve patient safety.

Read more:

By Matthew A. Taylor, Molly Quesenberry & 1 more. Wrong-site surgery (WSS) remains a significant and avoidable medical error, persisting despite decades of national and international efforts to prevent it. Pennsylvania is one of the few large governments...