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Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;Epub Sep 8.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.

ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is October 29, 2021.
Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11(8):e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period closes September 30, 2021.
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

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.

Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;Epub Jun 12.
Patient safety concerns in community pharmacies have been documented in the media. This study sought to examine the association of working conditions and patient safety. Results indicate that while all participants reported negative company climate and workflow, those in chain pharmacies reported significantly more fear of speaking up about patient safety issues than those in independent, big box, or grocery pharmacies.
Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21(1):842.
The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.

ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5. 

Error reporting is an essential contributor to system safety improvement. This article examines weaknesses in error reporting behaviors, characteristics of organizations and technologies that facilitate underreporting and ineffective report analysis. The piece shares recommendations to enhance adverse event reporting to support learning.
Fatima S, Soria S, Esteban- Cruciani N. BMC Med Educ. 2021;21(1):408.
Healthcare providers who are involved in a medical error and feel guilt, remorse, shame, and anger are sometimes referred to as “second victims”. This mixed-methods study surveyed medical residents about their well-being, coping strategies, and support following a self-perceived medical error. Residents reported feeling fear, shame, and feeling judged, and many used maladaptive strategies to cope.
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.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17(6):e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.

American Association for Physician Leadership. October 30-31, 2021.

Attaining high reliability remains a challenge throughout health care. This virtual session will focus on human error, safety culture, system thinking, and leadership as primary concepts driving progress toward reliable healthcare delivery.
Churruca K, Ellis LA, Pomare C, et al. BMJ Open. 2021;11(7):e043982.
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.
Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17(4):316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.
Grailey KE, Murray E, Reader T, et al. BMC Health Serv Res. 2021;21(1):773.
Psychological safety of healthcare teams can improve patient safety by encouraging workers to speak up about concerns or ideas. This thematic analysis of 62 studies on psychological safety highlighted the heterogeneity of study types, methods, and findings. The authors describe facilitators and barriers to increasing psychological safety and suggest further research into the topic.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18(14):7581.
Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.