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Davidson JE, Chechel L, Chavez J, et al. Am J Crit Care. 2021;30(5):375-384.
Nurses play a critical role in ensuring patient safety. Following the Joint Commission’s revised standards for titration of continuous intravenous medications, 730 nurses were surveyed about their experiences. Based on 159 comments, two overarching themes were identified: harms (e.g., erosion of workplace wellness, moral dilemma, patient safety) and professionalism (e.g., autonomy, nurse proficiency).
Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18(16):8391.
The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.
Cohen JB, Patel SY. Anesth Analg. 2021;133(3):816-820.
Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.
Preston-Suni K, Celedon MA, Cordasco’s KM. Jt Comm J Qual Patient Saf. 2021;47(10):673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic
Pring ET, Malietzis G, Kendall SWH, et al. Int J Surg. 2021;91:105987.
This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Wang M, Dewing J. J Nurs Manag. 2021;29(5):878-889.
Nursing leadership plays an important role in safety culture. This literature review found evidence of mediating effects between nursing leadership and a decrease in adverse patient outcomes. The authors conclude that mangers should emphasize workplace empowerment, leader-nurse relationship and the quality of the care environment as part of an effective workplace culture.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.
Dhahri AA, Refson J. BMJ Leader. 2021;Epub Aug 12.
Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.
Chong LSH, Kerklaan J, Clarke S, et al. JAMA Pediatr. 2021;Epub Jul 19.
Transgender and nonbinary individuals may delay or avoid seeking necessary healthcare due to fears of discrimination. This systematic review of qualitative studies of the perspectives of transgender youths identified six major themes regarding their experiences with accessing healthcare, including fear, vulnerability, and systemic barriers. The authors recommend several strategies to improve access to healthcare for transgender individuals.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.
Geerts JM, Kinnair D, Taheri P, et al. JAMA Netw Open. 2021;4(7):e2120295.
The COVID-19 pandemic has disrupted many aspects of health care delivery and has placed unprecedented pressure on health care workers. This consensus statement, based on input from an international panel of individuals with expertise in health leadership, health care, and public health, outlines 10 imperatives to guide health and public leaders during the post emergency stage of the pandemic. Imperatives addressed in the framework include supporting staff well-being and psychological health, preparing for future emergencies, managing the backlog of delayed care, and the importance of sustaining learning, innovations and collaborations that arose during the pandemic.

Andel SA, Tedone AM, Shen W, et al. J Adv Nurs. Epub 2021 Jul 10.

During the first weeks of the COVID-19 pandemic, 120 nurses were surveyed about nurse-to-patient staffing ratios, skill mix, and near misses in their hospitals. Personnel understaffing led to increased use of workarounds, and expertise understaffing led to increased cognitive failures, both of which shaped near misses. Hospital leaders should recognize both forms of understaffing when making staffing decisions, particularly during times of crisis.
Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30.
This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 
Silvera GA, Wolf JA, Stanowski A, et al. Patient Exp J. 2021;8(1):30-39.
Research has found that families and caregivers play a key role in identifying and preventing patient safety events.  Based on a national sample of hospitals, this study explored the impact of hospital visitation restrictions during the COVID-19 pandemic on patient experience and safety outcomes. Results indicate that hospitals with closed visitations experienced larger performance deficits across measures of medical staff responsiveness, fall rates, and sepsis rates.
Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19(S1):S14-S26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.