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Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD |

This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.

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Agency for Healthcare Research and Quality. 

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication. The Diagnostic Safety Supplemental Item Set 2024 survey results report is now available.

Institute for Safe Medication Practices. February 2024.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2024-2025 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission for this collection cycle closes April 19, 2024.
Perspective on Safety February 28, 2024

This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.

This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.

Stephen Hines headshot

Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.

Parikh K, Hall M, Tieder JS, et al. Pediatrics. 2024;Epub Feb 12.
Disparities in healthcare are emerging as a core patient safety issue. This population-based retrospective study examined disparities in the AHRQ pediatric safety indicators (PDIs). The findings indicate that Black and Hispanic pediatric patients have a higher risk of safety events (particularly sepsis and postoperative respiratory failure) compared to white patients. Findings were similar when comparing patients with Medicaid versus private insurance.
Michelson KA, Rees CA, Florin TA, et al. JAMA Pediatr. 2024;Epub Feb 12.
Diagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions. 
Kotwal S, Howell M, Zwaan L, et al. J Gen Intern Med. 2024;Epub Jan 26.
Achieving diagnostic excellence is a primary focus in health care. In this qualitative study, researchers interviewed hospitalists at five hospitals to examine clinical lessons learned from diagnostic errors and successes. Five themes were identified: excellence in clinical reasoning as a core skill; elucidating insights from patients and other care team members; reflecting on the diagnostic process; commitment to a growth mindset; and prioritizing self-care and well-being.

Hum Factors. 2024;66(3):633-769.

The ergonomics community has an established interest in medical error reduction. The 2021 International Ergonomics Association conference examined applications of human factors core concepts and methods to health care. Health care information technologies, workarounds, and nontechnical skills measurement are discussed through the lens of human factors.

Centers for Medicare & Medicaid Services, March 6 and 21, 2024. 12:00 - 1:00 PM (eastern).

Quality measurement intersects with patient safety and care improvement efforts to track weaknesses in distinct areas of performance. This webinar will share the experiences of government entities working to proactively reduce conditions that contribute to preventable patient harm through innovative use of quality measures.
Steel EJ, Janda M, Jamali S, et al. J Patient Saf. 2024;20:125-130.
Morbidity and mortality (M&M) conferences remain an important opportunity for patient safety education and feedback. This systematic review concluded that implementing standardized structures and processes within M&M meetings (e.g., standardized case selection), along with organizational support, is associated with learning and system improvement.
Sarkar U, Bates DW. JAMA Intern Med. 2024;Epub Feb 12.
Artificial intelligence (AI) has the potential to improve care delivery in a variety of healthcare settings. This article describes how AI tools can be leveraged in primary care and provides several examples, such as supporting clinician documentation, between-visit management and communication, and individualized decision support.  
New L, Lambeth T. Nurs Clin North Am. 2024;59:141-152.
The second victim phenomenon (SVP) refers to clinicians who experience continued psychological harm after involvement in a patient safety incident. This article outlines the physical, psychological, and professional manifestations of SVP, and how organizational programs can target the various stages of recovery to support healthcare workers after a patient safety incident.
Magerøy MR, Macrae C, Braut GS, et al. Front Health Serv. 2024;4:1275743.
Effective nursing leadership can improve patient safety climate. This qualitative study explored how nursing home leadership in Norway balances environmental and patient safety objectives. Respondents discussed the importance of communication, effective leadership, and building systems that further a culture of safety.
King L, Minyaev S, Grantham H, et al. Jt Comm J Qual Patient Saf. 2024;Epub Jan 7.
Patient- and visitor-activated rapid response systems (RRS) allow for earlier detection and prevention of clinical deterioration. This study sought perspectives of nurses and physicians on how patient and visitor involvement in RRS impacted care of other patients, their role in educating consumers on clinical deterioration, and the impact on the organization. The clinicians were generally positive about consumer involvement, but were also concerned that it could increase their workload, both by responding to more frequent activations, and by providing additional consumer education.
Januel J-M, Southern DA, Ghali WA. BMC Med Inform Decis Mak. 2023;21:385.
The International Classification of Diseases, 11th revision (ICD-11), introduces new features that enable a more detailed description of healthcare-related and patient safety events. This article provides examples of how ICD-11 allows coding for causal factors via "connecting terms." The authors state the new rich data provided by ICD-11 can improve adverse event reporting and research.
Hassinger AB, Velez C, Wang J, et al. J Clin Sleep Med. 2024;20:221-227.
The link between hours worked, hours slept, and medical errors has been the topic of much research, policy, and debate. This study captured sleep timing, regularity, efficiency, and duration via Fitbit in more than 3,500 interns (i.e., first year medical residents). There was no association between sleep duration and self-reported medical errors or burnout. Interns with the worst sleep health did have higher rates of burnout, compared to those with the best; however, as a group, interns had poor sleep health.
Gong Y, Chen Y. Stud Health Technol Inform. 2024;310:324-328.
Non-routine events (NRE), or deviations from optimal care, are latent safety threats, and their early identification and elimination can improve patient safety. This article uses an example of a medication error in the intensive care unit presented in a PSNet WebM&M case and commentary to describe NRE in the context of time-dependent tasks and teamwork, the use of real-world data to investigate them, and the challenges of identifying NRE.
Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. J Breast Imaging. 2024;Epub Jan 24.
Patients with limited English proficiency (LEP) are at higher risk of receiving suboptimal care, and they are less likely to receive preventative healthcare, including screening mammograms, than are native English speakers. This article lays out the benefits to patients of professional interpreters and best practices for engaging with the interpreter and patient in the breast radiology setting. Certified medical interpreters are recommended (and sometimes legally mandated) in place of ad hoc interpreters such as the patient's family members. While in-person professional interpreters are most effective, telephone and video are more accessible and less costly.
Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. J Med Syst. 2023;48:2.
Medication reconciliation at transition of care ensures patients are correctly receiving medications prescribed to them. This review explored studies on electronic medication reconciliation tools available to healthcare providers. Twelve tools were identified, four of which showed a reduction in adverse drug events or medication discrepancies; however, none showed a decrease in emergency room visits or hospital readmissions. Clinicians requested that these tools be incorporated into the medication ordering software and that they be made more user-friendly.
Ayre MJ, Lewis PJ, Phipps DL, et al. Front Psychiatry. 2023;14:1241445.
Medication errors and adverse drug events (ADE) are common in community settings including primary care, general practice, mental health services, and community pharmacy. This study focused on factors contributing to ADE, specifically in patients with mental illness receiving care in the community. Several factors were similar to those in other patient populations (e.g., workforce shortages) but some were also unique to this patient group, including lack of knowledge of psychotropic medications, difficultly in contacting and following up with patients, and diffusion of provider responsibility.

Aiken LH, Sermeus W, McKee M, et al. BMJ Open. 2024;14(2):e079931.

Physician and nurse burnout, job dissatisfaction, and intention to leave the job have increased in recent years, exacerbated by the pandemic. Results of this study of physicians and nurses in six European hospitals show poor work/life balance, high burnout, and high intention to leave. Among interventions to improve working conditions, nurses most frequently endorsed increased nurse staffing and physicians endorsed reducing bureaucracy and red tape. Individual mental health interventions received the lowest ratings.