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Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;34:499-511.
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.
Preston-Suni K, Celedon MA, Cordasco KM. Jt Comm J Qual Patient Saf. 2021;47:673-676.
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
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.
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.

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.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2022;37:188-194.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;17:e988-e994.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.
Goh HS, Tan V, Chang J, et al. J Nurs Care Qual. 2021;36:e63-e68.
Incident reporting systems are a common method for hospitals to detect patient safety events, but prior research has questioned whether these systems improve outcomes. Conducted in a nursing home, this study found that an existing incident reporting system redesigned to facilitate double-loop learning could improve nurses’ patient safety awareness and workplace practices, which could improve patient outcomes and safety.

Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

Jaffe S. Medpage Today. November 25, 2020.

Infection control is a primary safety mechanism that presents challenges for nursing homes. This news story highlights a Centers for Medicare and Medicaid Services program to fine nursing homes for infection control lapses during the COVID pandemic and discusses the potential residual impacts of the strategy.

Diagnosis (Berl)2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.   
Temkin-Greener H, Cen X, Li Y. Gerontologist. 2020;60:1303-1311.
Nurse staffing is an important factor in maintaining patient safety. In this study, the Nursing Home Survey on Patient Safety Culture was used to assess the association of registered nurse (RN) and certified nurse assistant (CNA) turnover on perceived patient safety culture. Results indicate that CNA turnover is associated with lower patient safety culture scores, but RN turnover is not. The authors conclude that patient safety culture improvements in nursing homes may be dependent on retaining a well-trained and skilled nursing staff.