Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.

… … Medication safety in ambulatory care settings is an area of growing concern . This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in … to improve medication safety in primary care settings. The ACTMed intervention will use health information …

Previous research has identified gaps in medication reconciliation practices among hospitalized children. This quality improvement found that increased utilization of a patient-friendly discharge medication platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge medication reconciliation in pediatric acute care patients.

Safety culture is recognized as an essential component of reducing or preventing errors and improving overall patient safety. This commentary calls for greater consistency in defining and measuring safety culture across settings. The authors describe challenges faced by patient safety professionals and researchers, and offer recommendations on overcoming them.

The quality improvement and patient safety (QIPS) curriculum is increasingly being added to resident education, but implementation and quality of these programs varies. In this study, continuous improvement specialists (CIS) were embedded in resident teams to create an A3, a quality improvement tool. A key component to the QIPS curriculum was aligning resident projects with quality improvement efforts already underway in the department.

Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.

A strong safety culture encourages error reporting and supports a blame-free environment, and is frequently measured to develop appropriate interventions. This review identified nearly 900 studies that assessed hospital safety culture with response rates from 4% to 100%. The authors identify several factors that influence response rate: remote distribution (i.e., electronic or sent via mail), timing (e.g., beginning/end of resident rotations, COVID-19), and length of survey.

… in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care … fears of litigation) to effective investigations. … Ramsey L, McHugh S, Simms-Ellis R, et al. Patient and family involvement in serious …

… BMC Emerg Med … Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest , and other … practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test …

… “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care. … Hannawa AF, Wu …

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

… BMC Health Serv Res … This study investigated the relationship between hospital staff perceived … improve staff well-being and safety attitudes. … Ellis LA, Tran Y, Pomare C, et al. "Time is of the essence": relationship between …

Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

… diagnosing child maltreatment. This article describes the implementation of a system-wide daily review of patients with concerns of … (e.g., history taking, injury identification, testing for occult injuries , and cognitive analysis) and to identify …

… both qualitative and quantitative methods. … Churruca K, Ellis LA, Pomare C, et al. Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals. BMJ Open. …

This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.

… systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions , to … clinical care quality and research. … Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system …

… a proactive, resilience-based development program reported the program as useful in preparing them to cope with errors; however, … training intervention designed to help them prepare for coping with error. J Eval Clin Pract. Epub 2021 Mar 6. …