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Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 
Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21:842.
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.

Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18:7581.
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.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

Horsham, PA: Institute of Safe Medication Practices; 2021
Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. J Nurs Care Qual. 2021;36:327-332.
Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;128:542-549.
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  
Stall NM, Johnstone J, McGeer AJ, et al. J Am Med Dir Assoc. 2020;21:1365-1370.e7.
In response to the COVID-19 pandemic, nursing homes limited access to visitors and family caregivers in order to limit virus transmission. Based on existing nursing home visitor policies, the authors developed data-driven, expert-reviewed guidance for re-opening Canadian nursing homes to family caregivers and visitors.
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. Adv Simul (Lond). 2020;5:13.
The authors of this article outline ten recommendations for safely reopening simulation facilities for clinical training in the post-lockdown phase of the COVID-19 crisis. The recommendations are based on national guidance and regulations, as well as international public health recommendations. Future reopening activities should focus on safety as well as flexibility principles, taking different contexts and facility characteristics into account.
Larouzee J, Le Coze J-C. Safety Sci. 2020;126:104660.
This article describes the development of the “Swiss cheese model,” (SCM) and the main criticisms of this model and the motivation for these criticisms.  The article concludes that the SCM remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.

Washington DC: National Quality Forum; 2020.

This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which focuses on safe care. The report outlines a stratum of actions on which to anchor work over the next decade to generate improvements and increase value. The authors recommend activities that enhance areas of focus such as information technology, equity and patient engagement.
Fitzsimons J. Int J Qual Health Care. 2021;33:mzaa051.
This article discusses the importance of leveraging quality improvement and patient safety science in acute and emergency situations. Methods and tools such as rapid learning cycles, huddles, team-based approaches, and debriefing and their applications to the COVID-19 pandemic are discussed.
Singh H, Sittig DF. Ann Intern Med. 2020;172:S92-S100.
This article describes the Safety-related EHR Research (SAFER) Reporting Framework, which facilitates reporting patient safety-focused EHR interventions through a sociotechnical lens. It discusses the benefits of a sociotechnical approach to reporting and components to operationalizing the SAFER framework, including necessary hardware and software, clinical content, a human-computer interface, workflow and communication, rules and regulations, and measurement and monitoring. SAFER is not intended to replace current research reporting guidelines, but complement their use.

Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Dora AV, Winnett A, Jatt LP, et al. MMWR Morb Mortal Wkly Rep. 2020;69:651-655.
This report describes an outbreak of COVID-19 among residents at one skilled nursing facility in Los Angeles between March 28 and April 23, 2020 and highlights the high asymptomatic prevalence of COVID-19 and unique risk to residents and staff at long-term care facilities. Authors emphasize that universal and serial RT-PCR testing, rapid isolation, and cohorting can disrupt transmission of the SARS-CoV-2 virus.
J Am Geriatr Soc. 2020;68:1131-1135.
This policy brief presents the American Geriatric Society’s recommendations about care for older adults in assisted living facilities during the COVID-19 pandemic. Recommendations focus on the production and distribution of personal protective equipment (PPE), testing and contact tracing, patient transfer between assisted living facilities and hospitals, infection control, and healthcare workforce issues. This brief reflects federal guidance as of April 15, 2020.