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Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2021;Epub Sept 13.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.

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.

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Betsy Lehman Center for Patient Safety.

Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care Research in Diagnosis Errors, or PRIDE, Learning Network. The effort examines de-identified error cases and shares collective assessments to support improvement.
Nikouline A, Quirion A, Jung JJ, et al. CJEM. 2021;Epub Apr 30.
Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.

This piece discusses Just Culture in EMS, where variation exists across systems, and challenges and opportunities to enhancing safety event reporting. 

Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates Consulting Group. He has served as a paramedic for over 20 years, and in his last operational role he was the Chief of EMS at Christian Hospital in North St. Louis. We spoke with him about the status of safety culture in EMS and challenge associated with safety event reporting.

Rand S, Smith N, Jones K, et al. BMJ Open. 2021;11(3):e043206.
Care home settings, such as nursing homes or residential care homes, present unique challenges to patient safety. This systematic review identified several gaps in the available safety measures used for quality monitoring and improvement in older adult care homes, including patient experience (e.g., quality of life or other resident-reported indicators of safety), psychological harm related to the care home environment, abusive or neglectful practices, and the absence of processes for integrated learning.
Lurvey LD, Fassett MJ, Kanter MH. Jt Comm J Qual Patient Saf. 2021;47(5):288-295.
High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;Epub Mar 2.
Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.
Danielis M, Destrebecq A, Terzoni S, et al. Dimens Crit Care Nurs. 2021;40(3):186-191.
While the effectiveness of medical emergency teams (MET) has been widely researched, critical incidents that occur during the response have not received the same attention. This retrospective study analyzed critical incidents that occurred during MET responses over a five-year period. They mainly occurred due to lack of compliance with protocols and lack of available supplies. Educational and organizational strategies may be effective in reducing critical events during MET.

Agency for Healthcare Research and Quality.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This survey supplement examines elements contributing to time availability, testing and referrals, and provider and staff communication. The set is to be used in conjunction with the Agency for Healthcare Research and Quality's Medical Office Survey on Patient Safety Culture (MOSOPS®). The supplemental item set was released in time for the upcoming data submission window for the MOSOPS (September 1 - October 20, 2021).
Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33(1):mzab045.
Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Centers for Medicare & Medicaid Services.
Hospital rating programs have received significant public attention, but concerns have been raised regarding their usefulness. This website provides resources to augment usability of this data including reports describing the methodology used by the Centers for Medicare and Medicaid Services to generate the information provided on the Hospital Compare website. In 2021 the process was adjusted to employ a 5-measure standardization process examining data submitted associated with mortality, readmission, patient experience, care timeliness/effectiveness and safety.
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33(1).
High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.
Fröding E, Gäre BA, Westrin Å, et al. BMJ Open. 2021;11(3):e044068.
In Sweden, patient suicide following contact with a healthcare provider is regarded a potential case of patient harm and must be investigated and reported to the Swedish supervisory authority. This retrospective study analyzed reported cases across three timeframes and concluded the investigations were largely suited to fit the requirements of the supervisory authority rather than an opportunity for organizational learning to advance patient safety. A 2019 PSNet Spotlight Case highlights systems issues that contributed to a patient’s suicide following discharge from the Emergency Department.    

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.