Safety Learning Research Articles

Hair endocannabinoids predict physiological fear conditioning and salivary endocannabinoids predict subjective stress reactivity in humans

On the basis of substantial preclinical evidence, the endogenous cannabinoid system has been proposed to be closely involved in stress reactivity and extinction of fear. Existing human research supports this proposal to some extent, but existing studies have used only a narrow range of tools and biomatrices to measure endocannabinoids during stress and fear experiments. In the present study we collected hair and saliva samples from 99 healthy participants who completed a fear conditioning and intrusive memory task. Subjective, physiological and biological stress reactivity to a trauma film, which later served as unconditional stimulus during fear conditioning, was also measured. We found that salivary endocannabinoid concentrations predicted subjective responses to stress, but not cortisol stress reactivity, and replicated previous findings demonstrating a sex dimorphism in hair and salivary endocannabinoid levels. Hair 2-arachidonoyl glycerol levels were significantly associated with better retention of safety learning during extinction and renewal phases of fear conditioning, while hair concentrations of oleoylethanolamide and palmitoylethanolamide were associated with overall physiological arousal, but not conditional learning, during fear conditioning. This study is the first to test the relationship between hair and salivary endocannabinoids and these important psychological processes. Our results suggest that these measures may serve as biomarkers of dysregulation in human fear memory and stress.

Patient Safety Incident Reporting and Learning Guidelines Implemented by Health Care Professionals in Specialized Care Units: Scoping Review.

Implementing Patient Safety Incident Reporting and Learning (PSIRL) guidelines is critical in guiding clinical practice and improving clinical outcomes in specialized care units (SCUs). There is limited research on the evidence of the implemented PSIRL guidelines in SCUs at the global level. This review aims to map the evidence of PSIRL guidelines implemented by health care professionals in specialized care units globally. A scoping review methodology, according to Joanna Briggs Institute, was adopted. The eligibility criteria were guided by the Population, Concept, and Context (PCC) framework, with the Population including health care professionals, the Concept including PSIRL guidelines, and the Context including specialized units globally. Papers written in English were searched from relevant databases and search engines. The PRISMA-ScR (Preferred Reporting Items for Scoping Reviews and Meta-Analyses extension for Scoping Reviews) checklist for used. The 13 selected studies were published from 2003 to 2023. Most articles are from the Netherlands and Switzerland (n=3), followed by South Africa (n=2). The nature of implemented PSIRL guidelines was computer-based (n=11) and paper-based incident reporting (n=2). The reporting system was intended for all the health care professionals within the specialized units, focusing on patients, staff members, and families. The outcomes of implemented incident reporting guidelines were positive, as evidenced by improved reporting of incidents, including medication errors (n=8) and decreased rate of incidents and errors (n=4). Furthermore, 1 study showed no change (n=1) in implementing the incident reporting guidelines. The implementation of reporting of patient safety incidents (PSIs) in specialized units started to be reported around 2002; however, the frequency of yearly publications remains very low. Although some specialized units are still using multifaceted interventions and paper reporting systems in reporting PSIs, the implementation of electronic and computer-based reporting systems is gaining momentum. The effective implementation of an electronic-based reporting system should extend into other units beyond critical care units, as it increases the reporting of PSIs, reducing time to make an informed reporting of PSIs and immediate accessibility to information when needed for analysis. The evidence on the implementation of PSI reporting guidelines in SCUs comes from 5 different continents (Asia, Africa, Australia, Europe, and North America). However, the number identified for certain countries within each continent is very minimal.

Safer Type 1 Diabetes Care at Home: SEIPS-based Process Mapping with Parents and Clinicians.

The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D. A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA). Eight (57%) of the 14 children who had home visits experienced 18 errors (31 per 100 medications). Four errors in two children resulted in harm, and 13 had the potential for harm. Two injuries occurred when parents failed to treat severe hypoglycemia and lethargy, and two were due to repeated failures to administer insulin at home properly. In SEIPS-based process maps, high-risk errors occurred during communication between the clinic and home or in management at home. Two FMEAs identified interventions to better communicate with families and support home care, especially during evolving illness. Using SEIPS-based process maps informed by multimodal methods to identify medication errors and treatment delays, we found errors were common. Better support for managing acute illness at home and improved communication between the clinic and home are potentially high-yield interventions.

Integrating Implementation Science in a Quality and Patient Safety Improvement Learning Collaborative: Essential Ingredients and Impact.

There is a current lack of research exploring the contextual factors of why and how quality improvement collaboratives (QICs) work. To this end, a mixed methods study was undertaken to improve our understanding of what works for whom and in what context among participants in a nationwide Canadian QIC. The authors used a mixed methods approach consisting of a written survey and 30-to-45-minute telephone interviews with collaborative team members, coaches, and senior leaders of participating safety improvement project (SIP) organizations to identify the essential elements of an integrated approach involving implementation science/knowledge translation, quality improvement (QI), patient safety, and collaborative learning/networked approach to enhancing safety and quality and building implementation capabilities. Survey data were analyzed using descriptive statistics. Interview data were analyzed by three team members using thematic analysis and development of an emergent coding schema. Four themes emerged as the essential elements: (1) integrating implementation science into the QI/patient safety learning collaborative; (2) reinforcing of and opening eyes to implementation science by an expert implementation specialist; (3) valuing the sense making and strategies shared by coaches; and (4) experiencing challenges to implementation amplified by the COVID-19 pandemic. Teams also reported improvements in teamwork and patient outcomes as a result of participating in the QIC. This study's findings provide deeper insight into the "essential ingredients" (expert implementation specialist, coaches) grounded in an integrated approach that drew from QI, patient safety, and implementation science. Organizations can use the key learnings on how best to implement quality and safety projects by leveraging the sense making of the expert implementation specialist and coaches in an integrated networked learning approach.

Patient safety culture at the unit level of a tertiary hospital in South Africa: a survey study.

Patient safety research is scarce in developing countries. Estimates of patient harm due to healthcare processes in resource-poor settings are thought to be greater than those in developed countries. Ideally, errors in healthcare should be seen as opportunities to improve the future quality of care. This study aimed to investigate patient safety culture within high-risk units of a tertiary hospital in South Africa. A quantitative, descriptive, cross-sectional methodology, using a survey questionnaire that measured 10 safety dimensions and one outcome measure among clinical and nursing staff, was employed. Two hundred participants completed the survey questionnaire. Areas of strength identified by the participants included organizational learning (91.09%), staff attitudes (88.83%), and perceptions of patient safety (76.65%). Dimensions that have potential for improvement included awareness and training (74.04%), litigation (73.53%), feedback and communication about errors (70.77%), non-punitive response to error reporting (51.01%), size and tertiary level of the hospital (53.76%), and infrastructure and resources (58.07%). The only dimension identified as weak was teamwork and staffing (43.72%). In terms of the patient safety grade, respondents graded their own units highly but graded the hospital as a whole as having a poor patient safety grade. There are still significant gaps in the quality of care provided at this tertiary hospital. The current patient safety culture is perceived as punitive in nature with regard to reporting adverse events. It is advised that targeted patient safety improvements be made, followed by further investigation.

Transcranial direct current stimulation impairs updating of avoidance-based associative learning.

Exposure-based psychotherapies for the treatment of anxiety- and fear-based disorders rely on "corrective" associative learning. Namely the repeated confrontation with feared stimuli in the absence of negative outcomes allows the formation of new, corrected associations of safety, indicating that such stimuli no longer need to be avoided. Unfortunately, exposure-facilitated corrective learning tends to be bound by context and often poorly generalizes. One brain structure, the prefrontal cortex, is implicated in context-guided behavior and may be a relevant target for improving generalization of safety learning. Here, we tested whether inhibition of the left prefrontal cortex causally impaired updating of context-bound associations specifically or, alternatively, impaired updating of learned associations irrespective of contextual changes. Additionally, we tested whether prefrontal inhibition during corrective learning influenced subsequent generalization of associations to a novel context. In two separate experiments, participants received either 10 min of 2 mA cathodal transcranial direct current stimulation (tDCS) over EEG coordinate F3 (Experiment 1 n = 9, Experiment 2 n = 22) or sham stimulation (Experiment 1 n = 10, Experiment 2 n = 22) while previously learned associations were reversed in the same or a different context from initial learning. Next, to assess generalization of learning, participants were asked to indicate which of the previously seen images they preferred in a novel, never seen before context. Results indicate that tDCS significantly impaired reversal irrespective of context in Experiment 2 only. When taking learning rate across trials into account, both experiments suggest that participants who received sham had the greatest learning rate when reversal occurred in a different context, as expected, whereas participants who received active tDCS in this condition had the lowest learning rate. However, active tDCS was associated with preferring the originally disadvantageous, but then neural stimulus after stimulus after reversal occurred in a different context in Experiment 1 only. These results support a causal role for the left prefrontal cortex in the updating of avoidance-based associations and encourage further inquiry investigating the use of non-invasive brain stimulation on flexible updating of learned associations.

Analysis Dimension of Healty Work Environment for Successful Patient Safety Incident Reporting: A Cross Sectional Study

Incident reporting of patient safety is the first step in improving patient safety through learning from previous incidents. However, barriers to incident reporting caused by work environment factors make the patient safety incident system not run well in various countries. This study analyzes nurses’ dimensions of a healthy work environment toward reporting patient safety incidents. This study used an observational analytic design with a cross-sectional approach. This study was conducted in a regional hospital in West Nusa Tenggara province in October - November 2022 with a total sample of 151 nurses working in the inpatient room. Sample determination used a quota sampling technique. Measurement of a healthy work environment was adopted from the HWE Tools and Measurement of incident reporting. The questionnaire was adopted from the Patient Safety Incident Reporting and Learning Systems. Data collection techniques implemented primary data questionnaires and multiple linear regression tests. The results showed a relationship between communication, collaboration, decision-making, staff suitability, recognition, and leadership to patient safety incident reporting with a p-value of 0.001 each (p <0.05). The most dominant relationship is Recognition (B=0.39, p=0.001). Recognition means stimulating a person’s psychological growth and a positive mindset to complete tasks, solve problems, overcome obstacles, and bounce back from difficult situations. Therefore, individual attitudes alone are not enough to make individuals behave to report or not report incidents but must be supported by the wishes of those who have great influence in the environment and want individuals to report if an incident occurs.

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis

BackgroundThe implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems,...

The effect of acute nicotine administration on human delay cued and context fear conditioning.

Nicotine has been shown to facilitate hippocampal-dependent context fear conditioning (FC), but not hippocampal-independent delay cued fear conditioning. Studies examining the effects of nicotine on learned fear have been exclusively limited to nonhumans. The present study aimed to translate nonhuman findings by investigating the effects of nicotine on cued and context fear in humans using a virtual reality (VR) analog of the fear conditioning task. Sixty-seven nicotine-using undergraduates were randomly assigned to receive either a 2 mg nicotine or placebo lozenge prior to conditioning. During conditioning, participants were confined to a virtual room and were conditioned to green floodlight presentations (conditioned stimulus [CS +]) paired with a wrist shock (unconditioned stimulus [US]). A red floodlight served as the CS- during which no shock occurred. Delay cued and context fear testing immediately followed conditioning. Physiological skin conductance responses (SCRs) were recorded continuously throughout all sessions. Nicotine enhanced context fear conditioning such that SCRs to the shock-paired context were significantly greater for the nicotine group than the placebo group. Nicotine did not enhance delay cued fear. Exploratory analyses examining the relationship between fear conditioning and self-reported anxiety revealed that relative to those with lower levels of trait anxiety, nicotine-treated individuals with higher trait anxiety levels were less likely to demonstrate differential conditioning to the shock-paired cue. These findings support abundant nonhuman literature indicating that nicotine facilitates hippocampus-dependent versions of fear conditioning in humans. Results also suggest a role for dysregulated safety learning in pathological anxiety, which may be exacerbated by nicotine use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Methods and Processes for First Nations Health Curriculum Development for Nursing, Medicine, Dentistry and Allied Health Entry-Level Programs: A Scoping Review

The inclusion of First Nations health curricula in programs is critical for the development of culturally safe graduates, however, less is known about how to embed content into curriculum in ways that reflect best practice and pedagogy. The aim of this scoping review was to describe methods and processes of First Nations health curriculum development in nursing, medical, dentistry, and allied health entry-level programs in international peer-reviewed journals. Systematic searches of databases were completed including CINAHL, Proquest, Medline, and Informit; with additional searches in Google Scholar and First Nations-led journals. A total of 104 articles met inclusion criteria; the majority relating to medicine ( n = 38) and nursing/midwifery ( n = 17) student cohorts. Methods and processes for embedding First Nations health content are described, including First Nations-led development and co-leadership, resulting in a suggested model for curriculum development. Evidence-informed curriculum development is critical to ensure effective methods and processes are adopted and cultural safety learning outcomes are achieved.

The fear that remains: Associations between trauma, related psychopathology, and fear-potentiated startle in youth resettled as refugees.

Fear-potentiated startle (FPS) can be used to measure fear and safety learning-behaviors affected by trauma that may map onto posttraumatic stress disorder (PTSD). Therefore, FPS could be a candidate biomarker of trauma-related psychopathology and a potential identifier of trauma-exposed youth in need of focused treatment. We enrolled n=71 (35 females, Mage =12.7 years) Syrian youth exposed to civilian war trauma. Eyeblink electromyogram (EMG) data from a differential conditioning FPS paradigm were obtained 2.5 years after resettlement. Youth provided self-report of trauma exposure (Harvard Trauma Questionnaire) and PTSD symptoms (UCLA PTSD Reaction Index). While FPS during conditioning was not associated with symptoms, associations with psychopathology emerged in fear extinction. Probable PTSD was associated with FPS in the last block of extinction, such that FPS to threat cue was significantly greater in the PTSD+ group compared to the PTSD- group at the end of extinction (F=6.25, p=.015). As with adults, we observed a deficit in extinction learning but not fear conditioning in youth with PTSD. These results support the use of trauma-informed cognitive behavioral therapy based on the learning principles of extinction in youth with PTSD.

Counterconditioning reduces contextual renewal in a novel context but not in the acquisition context

As extinction is a context-dependent form of learning, conditioned responses tend to return when the conditioned stimulus (CS) is encountered outside the extinction context, known as contextual renewal. Counterconditioning is a technique that may lead to a more persistent reduction of the conditioned response. However, the effects of aversive-to-appetitive counterconditioning on contextual renewal in rodent studies are mixed. Further, research in humans is sparse, particularly direct statistical comparisons between counterconditioning and standard extinction techniques within the same study. Using a causal associative learning framework (the allergist task) implemented online, we compared the effectiveness of counterconditioning to standard extinction in preventing the renewal of judgements on the allergic properties of different food items (CSs). In a between-subjects design, 328 participants first learned that particular food items (CSs) lead to an allergic reaction in a specific restaurant (context A). Next, one CS was extinguished (no allergic reaction) while another CS was counterconditioned (positive outcome) in restaurant B. Causal judgements of the allergic properties of food items occurred in either the response acquisition context (ABA group, N = 112), the response reduction context where extinction and counterconditioning had occurred (ABB group, N = 107), or a novel context (ABC group, N = 109). Results showed that counterconditioning, compared to extinction, diminished the renewal of causal judgements to the CS in a novel context (ABC group). Still, casual judgements returned for both counter-conditioned and extinguished CSs in the response acquisition context (ABA group). Counterconditioning and extinction were similarly effective at preventing recovery of causal judgements in the response reduction context (ABB group); however, only in context B did participants choose the counter-conditioned CS as less likely to cause an allergic reaction in comparison to the extinguished CS. These findings indicate scenarios in which counterconditioning is more effective than standard extinction at diminishing the return of threat associations, with implications for improving the generalization of safety learning.

Chronic unilateral inhibition of GABA synthesis in the amygdala increases specificity of conditioned fear in a discriminative fear conditioning paradigm in rats

Neural activity in the amygdala is critical for fear learning. In anxiety disorder patients, bilateral hyperactivity of the amygdala can be observed. This hyperactivation is often associated with the facilitation of fear learning and/or over-generalization of conditioned fear. In contrast, hypoactivity of the amygdala, e.g. by pharmacological interventions, attenuates or blocks fear learning. To date, little is known about how neural excitability of the amygdala affects specificity or generalization of fear. Therefore, the present study utilized chronic inhibition of GABA synthesis in the amygdala to increase excitability and investigated the effect on the specificity of fear learning. In rats, unilateral cannulas aiming at the amygdala were implanted. The cannulas were connected to subcutaneously implanted osmotic mini pumps that delivered either the GABA synthesis inhibitor L-allylglycine or its inactive enantiomer D-allylglycine. Following one week of chronic GABA synthesis manipulation, the rats were submitted to a discriminative fear conditioning protocol. In addition, anxiety-like behavior in the light-dark box was measured. Our data show that chronic unilateral L-AG infusions into the amygdala improve the specificity of learned fear, support safety learning, and reduce fear generalization and anxiety. This data demonstrates that moderately increased amygdala excitability can be beneficial for the specificity of fear learning and highlights the potential application for therapeutic interventions.

In safe hands: Attachment figures’ safety properties and the link with attachment style

According to the Learning Theory of Attachment, naturalistic learning experiences about others' responsiveness during distress are an underlying mechanism in the development of attachment. Previous studies have demonstrated attachment figures' unique safety-inducing effects in highly controlled conditioning procedures. Yet, neither have studies examined the presumed influence of safety learning on state attachment, nor have they examined how attachment figures' safety-inducing effects relate to attachment styles. To address these gaps, a differential fear conditioning paradigm was used in which pictures of participants’ attachment figure and two control stimuli served as safety cues (CS-). US-expectancy and distress ratings were measured as indicators of fear responding.Results indicate that attachment figures evoked enhanced safety responding compared to control safety cues at the start of acquisition, which was maintained throughout acquisition and when presented together with a danger cue. Attachment figures' safety-inducing effects were reduced in individuals with higher attachment avoidance, although attachment style did not affect the rate of new safety learning. Finally, safe experiences with the attachment figure in the fear conditioning procedure resulted in diminished anxious state attachment. Adding to previous work, these findings underscore the importance of learning processes for attachment development and attachment figures’ provision of safety.

A Safe Place to Learn: Peer Research Qualitative Investigation of gameChange Virtual Reality Therapy.

Automated virtual reality (VR) therapy has the potential to substantially increase access to evidence-based psychological treatments. The results of a multicenter randomized controlled trial showed that gameChange VR cognitive therapy reduces the agoraphobic avoidance of people diagnosed with psychosis, especially for those with severe avoidance. We set out to use a peer research approach to explore participants' experiences with gameChange VR therapy. This in-depth experiential exploration of user experience may inform the implementation in clinical services and future VR therapy development. Peer-led semistructured remote interviews were conducted with 20 people with a diagnosis of psychosis who had received gameChange as part of the clinical trial (ISRCTN17308399). Data were analyzed using interpretative phenomenological analysis and template analyses. A multiperspectival approach was taken to explore subgroups. Credibility checks were conducted with the study Lived Experience Advisory Panel. Participants reported the substantial impact of anxious avoidance on their lives before the VR intervention, leaving some of them housebound and isolated. Those who were struggling the most with agoraphobic avoidance expressed the most appreciation for, and gains from, the gameChange therapy. The VR scenarios provided "a place to practise." Immersion within the VR scenarios triggered anxiety, yet participants were able to observe this and respond in different ways than usual. The "security of knowing the VR scenarios are not real" created a safe place to learn about fears. The "balance of safety and anxiety" could be calibrated to the individual. The new learning made in VR was "taken into the real world" through practice and distilling key messages with support from the delivery staff member. Automated VR can provide a therapeutic simulation that allows people diagnosed with psychosis to learn and embed new ways of responding to the situations that challenge them. An important process in anxiety reduction is enabling the presentation of stimuli that induce the original anxious fears yet allow for learning of safety. In gameChange, the interaction of anxiety and safety could be calibrated to provide a safe place to learn about fears and build confidence. This navigation of therapeutic learning can be successfully managed by patients themselves in an automated therapy, with staff support, that provides users with personalized control. The clinical improvements for people with severe anxious avoidance, the positive experience of VR, and the maintenance of a sense of control are likely to facilitate implementation.

Safety Learning: Explaining and Treating Maladaptive COVID-19 Concerns

Safety Learning: Explaining and Treating Maladaptive COVID-19 Concerns

Self-Assessment of Patient Safety Reporting and Learning System in Private Hospitals in Indonesia.

Hospitals are required to implement patients safety incident (PSI) reporting, analysis, and problem-solving. Self-assessment is important for exploring gaps and strengthening PSI reporting and learning system. This study examined PSI reporting and learning systems through self-assessment based on WHO guidance, analysis of section scores by hospital class, and analysis of section relationships. This cross-sectional study was conducted on 193 health workers from 47 Indonesian non-profit private hospitals selected using non-probability sampling. Samples in each hospital consisted of seven hospital staff, including quality and patients' safety committee, infectious diseases control committee, manager/head of nursing, as well as functional staff comprising doctors, nurses, pharmacists, and nutritionists. Six aspects based on WHO guidance were measured in this study namely 1) environment for reporting, 2) reporting rules and content, 3) analysis and investigation, 4) governance, 5) action and learning, as well as 6) patients' and family engagement. The data obtained were analyzed using univariate and bivariate analysis. The results showed that the total average score was 64.7 ± 3.3, and the average score on all components of PSI reporting and learning system was minimum 59.3 and maximum 69.6 of a total score of 100. The lowest average score was found in patients' and family engagement component at 59.3 ± 8.4. Class B hospitals had higher average scores on each component than class C and D hospitals, except on the action and learning and patients' and family engagement section. There was a significant positive linear correlation between each section of PSI reporting and learning system (p-value < 0.01). The PSI reporting and learning system in hospitals is in need of improvement across all aspects. One specific area that requires attention is the implementation of mechanisms for patient and family engagement, which can play an important role in promoting safety programs.

Threat of war on cognitive development of refugee children

War trauma is often accompanied by poor living conditions in the new environment in a manner preserving or even deteriorating the negative influences of war. Several researchers have investigated the refugee experiences of displaced children. Often they have focused on the detrimental effects of war on psychological well-being, mental health, educational settings, social adaptation, quality of nutrition, financial difficulties, safety and language learning experiences. Each of these effects has been proven to negatively affect cognitive abilities; however, the current study reviews the key studies to reveal the cognitive and linguistic outcomes of holding refugee status in the early childhood period. Doing this, we aim to reveal the adverse conditions that affect refugee children’s three core abilities of executive functions, namely working memory, inhibitory control and shifting. In addition to cognitive outcomes, we present the factors that may affect these children’s mother tongue development and their experiences with the language spoken in the host country in the context of schooling. This study suggests that refugee children should be assessed for their cognitive and language abilities after arriving in the country of resettlement so that their needs can be identified and addressed effectively. Caretakers should also be given both psychological and financial support to enrich their children’s language and cognitive input. Also, the outcomes of the research in this field should be effectively shared with different stakeholders from the caregivers and teachers of the refugee children to the NGOs and policymakers responsible to take solid actions to counter the adverse effects of displacement.

Patient Identification of Diagnostic Safety Blindspots and Participation in "Good Catches" Through Shared Visit Notes.

Policy shifts toward health information transparency provide a new opportunity for patients to contribute to diagnostic safety. We investigated whether sharing clinical notes with patients can support identification of "diagnostic safety blindspots"-potentially consequential breakdowns in the diagnostic process that may be difficult for clinical staff to observe. We used mixed methods to analyze patient-reported ambulatory documentation errors among 22,889 patients at three US health care centers who read ≥ 1 visit note(s). We identified blindspots by tailoring a previously established taxonomy. We used multiple regression analysis to identify factors associated with blindspot identification. 774 patients reported a total of 962 blindspots in 4 categories: (1) diagnostic misalignments (n = 421, 43.8%), including inaccurate symptoms or histories and failures or delay in diagnosis; (2) errors of omission (38.1%) including missed main concerns or next steps, and failure to listen to patients; (3) problems occurring outside visits (14.3%) such as tests, referrals, or appointment access; and (4) multiple low-level problems (3.7%) cascading into diagnostic breakdowns. Many patients acted on the blindspots they identified, resulting in "good catches" that may prevent potential negative consequences. Older, female, sicker, unemployed or disabled patients, or those who work in health care were more likely to identify a blindspot. Individuals reporting less formal education; those self-identifying as Black, Asian, other, or multiple races; and participants who deferred decision-making to providers were less likely to report a blindspot. Patients who read notes have unique insight about potential errors in their medical records that could impact diagnostic reasoning but may not be known to clinicians-underscoring a critical role for patients in diagnostic safety and organizational learning. From a policy standpoint, organizations should encourage patient review of visit notes, build systems to track patient-reported blindspots, and promote equity in note access and blindspot reporting.

A qualitative exploration of undergraduate nursing students' experience of emotional safety for learning during their clinical practice

BackgroundDuring their clinical practice, nursing students learn to manage patient safety through their experiences, emotions, and interpersonal relationships. ObjectivesTo explore contextual and mechanistic factors that facilitate a sense of emotional safety for learning in nursing students, particularly regarding patient safety events experienced during their placements. DesignA descriptive qualitative study using narratives and thematic analysis. SettingsA university in Northern Italy. ParticipantsUndergraduate nursing students recruited through purposive sampling. MethodsTwenty cases relevant to the present study were selected from the “Sharing LearnIng from Practice for Patient Safety” (SLIPPS) project database containing 100 narratives collected using the patient safety learning Event Recording Tool. The data were analysed using thematic analysis according to Braun & Clarke's methodology. The themes that emerged from the thematic analysis were rearranged in Context-Mechanism-Outcomes. ResultsStudents identified clinical practice experiences as important occasions for their personal and professional development. Emotional safety and tutoring were the elements that effectively “govern” the students' learning and development process. ConclusionsEmotional safety is key for nursing students because it enables them to constructively overcome any relational and emotional tensions that may develop during their clinical placements.