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Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17(6):458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.

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.

Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28(2):188-204.
This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2021;Epub Aug 20.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Van Eerd D, D'Elia T, Ferron EM, et al. J Safety Res. 2021;78:9-18.
Working conditions for healthcare workers can affect patient safety. Conducted at four long-term care facilities in Canada, this study found that a participatory organizational change program can have positive impacts on identifying and reducing musculoskeletal disorder hazards for employees, including slips, trips, falls, and ergonomic hazards. Key factors for successful implementation of the change program include frontline staff involvement/engagement, support from management, and training.
Hoyle JD, Ekblad G, Woodwyk A, et al. Prehosp Emerg Care. 2021:1-8.
Inaccurate assessment of pediatric patient weight can lead to medication dosing errors. In simulated pediatric scenarios, pre-hospital emergency medical services (EMS) crews obtained patient weight using one or more of three methods: asking parent, using patient age, and Broselow-Luten Tape (BLT). BLT was the most frequent method used and patient age resulted in the most frequent dosing errors. Systems-based solutions are presented.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Bartman T, Merandi J, Maa T, et al. Jt Comm J Qual Patient Saf. 2021;47(8):526-532.
Safety II is a proactive approach to improving patient safety by learning from what goes right in healthcare. A US children’s hospital developed three tools for frontline clinicians to recognize, mitigate, and learn from potential safety issues at the bedside.
Jaam M, Naseralallah LM, Hussain TA, et al. PLOS ONE. 2021;16(6):e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
Park J, Saha S, Chee B, et al. JAMA Netw Open. 2021;4(7):e2117052.
The patient-provider relationship plays an important role in the delivery of safe, quality health care.  Using electronic encounter notes, this qualitative study describes physician language used to express negative and positive attitudes toward the patient. While positive attitudes were generally expressed via explicit language (e.g., direct compliments), negative attitudes were not explicit and often expressed through questioning patient credibility, disapproval of patient reasoning or self-care, stereotyping, portraying the patient as difficult, and emphasizing physician authority over the patient.

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.

Allison MK, Marshall SA, Stewart G, et al. J Emerg Med. 2021;Epub Jun 29.
Transgender and gender nonbinary (trans/NB) people can face discriminatory behaviors when accessing health care services. Trans/NB patients were interviewed about their experiences accessing care in emergency departments. Four themes were uncovered: 1) system and structural issues; 2) interactions with clinicians/staff; 3) perceptions of clinician knowledge and education; and 4) impact on future health and healthcare access. Recommendations for improvement were provided at the system and clinician level.