The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next online session is August 2-3, 2023.

Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The session will explore the successful application of high reliability concepts at the Veterans Health Administration. This is the fifth in a series of offerings from the Alliance supporting its work to improve safety.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 

Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490 members. This report highlights 2022 trends, activities, and outcomes of initiatives at a 21-state PSO. Sections of the report include high-level review of falls and inequities, workplace violence issues, safe table data analysis, and CHPSO's new data platform capabilities.

Patient safety is a stated goal across health care. This in-person conference under the theme of "Changes, Challenges, & Champions" will bring improvement experience from the front line to regional audiences. The event will feature tracks examining health equity, workforce support and general patient safety and a closing keynote by former nurse RaDonda Vaught.

Efforts to incorporate respect and patient safety concepts into medical training have been inspired by the work and leadership of Dr. Lucian Leape, founding chairman of the Lucian Leape Institute. This annual award was established to recognize individuals and organizations that focus on developing medical student and resident skills in quality and safety improvement. The 2023 application process closes October 31, 2023. 

Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an analysis of transfusion-related errors reported to a national improvement program in the United Kingdom. The 2022 report recommends enhancing focus on underreporting and emergency department report activity as targets for study. Previous reports in the series are available.