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Aho-Glele U, Pomey M-P, Gomes de Sousa MR, et al. Patient Exp J. 2021;8(1):45-58.
Patient engagement is an important strategy to improve quality and safety of care. This article describes the development of a tool for managers to assess patient engagement strategies within their health system. The tool contains four sections: (1) describing the healthcare organization; (2) gathering general information on their current patient engagement strategies; (3) assessing patient engagement strategies; and (4) describing their involvement in patient safety committees. The tool is intended to assess the health system’s integration of patient engagement for patient safety and to track changes over time.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is December 10, 2021.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2021.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2020 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication efforts, and the convening of patient safety conferences for the state.
Agency for Healthcare Research and Quality.
Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture and a range of content related to the successful use of the surveys. Topics covered include organizational characteristics required for successful web-based distribution of the survey and best practices for formatting, programming, and administering the surveys in a variety of environments. 

de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.

The assessment of patient safety culture is critical for understanding the success of organizational efforts to provide a foundation for improvement work. This report examines tools used in a variety of countries to assess culture and underscores the value that the assessment of culture can bring to understanding problems and implementing sustainable improvements.
Keers RN, Hann M, Alshehri GH, et al. PLOS ONE. 2020;15(2):e0228868.
This study described medication omission errors occurring in inpatient mental health hospitals in the United Kingdom. Of over 18,000 scheduled medication doses, 2,700 omissions were identified (omission rate, 14.6%). One-third of all omissions were considered ‘preventable.’ The omission rate among ‘time critical’ medications (those that carry risk of harm if a single dose is omitted) was 19.3%, and half of these omissions were considered ‘preventable’. Predictors of omission errors are discussed, including administration route and medication type. Analyses found that administration route, medication class and time of medication administration rounds were significantly associated with omission errors. These findings should inform future research and quality improvement initiatives designed to reduce the burden of omission errors in psychiatric hospitals.
Siegal D, Swift J, Forget J, Slowick T. J Healthc Risk Manag. Harnessing the power of medical malpractice data to improve patient care. 2019 Nov 24. doi: 10.1002/jhrm.21393. [Epub ahead of print]
This paper describes the experience of one hospital that analyzed its medical malpractice claims to identify practice or policy changes to reduce risk and improve patient safety. Institutional changes in emergency department ultrasound coverage, obstetrics communication, and airway management training are discussed.  
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem Association of Pennsylvania. Q3 Health Innovation Partners.
Local efforts that draw from the experience of its leaders serve an important role in generating patient safety improvement. This collaboration merges the efforts of three organizations as participants in the federal Partnerships for Patients initiative to engage their constituents in regionally focused safety and quality improvement.
Deilkås ECT, Hofoss D, Husebo BS, et al. PloS one. 2019;14:e0218244.
Researchers deployed the Norwegian version of the Safety Attitudes Questionnaire, a measure of safety culture, across long-term care facilities and found significant variations in scores. They conclude that safety culture measurement may be useful to align resources with needs to support patient safety.
Odell DD, Quinn CM, Matulewicz RS, et al. Journal of the American College of Surgeons. 2019;229:175-183.
Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.
Smith PK, Amster A. Joint Commission journal on quality and patient safety. 2019;45:304-314.
This commentary describes how one health system developed and utilized an inpatient safety composite measure to track hospital-level performance on a select set of adverse events. The authors found that the tool successfully quantified improvement over time and suggest it can be used by other hospitals and health systems.
Hoag JR, Resio BJ, Monsalve AF, et al. JAMA network open. 2019;2:e191912.
This cross-sectional study examined outcomes for Medicare patients undergoing complex cancer surgery at U.S. News and World Report top-ranked cancer hospitals and their affiliates. Investigators found that surgery performed at affiliated hospitals was associated with higher 90-day mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the study. The authors suggest that while affiliated hospitals may share branding with top-ranked cancer facilities, further study of such networks is necessary to inform care for cancer patients.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Jt Comm J Qual Patient Saf. 2019;45(3):164-169.
High reliability industries such as aviation ensure safety amidst high-risk work environments and rapidly changing conditions. Achieving high reliability in health care remains an ongoing challenge. Researchers surveyed hospitals in the Children's Hospitals' Solutions for Patient Safety (CHSPS) network to understand the extent of adoption of high reliability practices. Of the 46 hospitals that responded to the survey, about 80% were determined to be approaching high reliability using the High Reliability Health Care Maturity model described in the study. The authors conclude that the majority of hospitals in the CHSPS network demonstrate opportunity to improve across all three high reliability domains in the model including leadership, safety culture, and robust process improvement. A past PSNet interview discussed high reliability as it relates to health care.
Simons P, Houben R, Reijnders P, et al. Journal of patient safety. 2018;14:193-201.
Organizations with robust safety culture, as measured by AHRQ's Hospital Survey on Patient Safety Culture, have improved objective measures of safety. Researchers compared the AHRQ survey to a factorial survey examining safety behavior among employees in a radiotherapy department. The two surveys yielded similar results, while the factorial survey added that staff were more likely to report safety concerns if they caused patient harm.
ISMP; Institute for Safe Medication Practices.
Standardized practices have not been uniformly adopted to support safe IV medication therapy. This risk assessment tool will help organizations proactively identify process weaknesses that could contribute to patient harm. Users of the guide can also contribute to a national effort to collect data on current IV push practices. The data collection process is now closed.
Brauner D, Werner RM, Shippee TP, et al. Health Aff (Millwood). 2018;37(11):1770-1778.
The Centers for Medicare and Medicaid Services launched Nursing Home Compare in 2002 to prompt public reporting on the quality and safety of care provided in United States nursing homes. Researchers found that when comparing nursing homes' performance on a variety of Nursing Home Compare measures to performance in several specific areas of safety, the association was inconsistent. They suggest that Nursing Home Compare does not accurately capture patient safety performance in nursing homes in its current form.