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Alanazi FK, Sim J, Lapkin S. Nurs Open. 2022;9:30-43.
Nurse attitudes towards patient safety culture have shown to impact missed nursing care, iatrogenic harm, and other adverse events. This review synthesizes research on nurses’ safety attitudes and subsequent impact on patient outcomes. While most data on adverse events was self-reported, nurses indicated an improved safety culture resulted in fewer reported adverse events. Nurse managers can play an important role in improving patient safety culture and outcomes in their hospital units.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2022;31:526-540.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.
Paulin J, Kurola J, Koivisto M, et al. BMC Emerg Med. 2021;21:115.
Emergency medical services (EMS) personnel are in the unique position of providing medical care outside of a healthcare facility. This prospective cohort study conducted in Finland explored the outcomes of patients who were treated by EMS personnel without going to the ED. Findings indicate that 80% of patients treated by EMS did not have any re-contact with the healthcare system (e.g., re-contacted EMS, went to the ED, were hospitalized), suggesting that EMS management of these patients is relatively safe.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
Willis JS, Tyler C, Schiff GD, et al. Am J Med. 2021;134:1101-1103.
Telemedicine has become a more accepted care mode due to the COVID pandemic and general rural care access issues. This commentary suggests a 5-part framework for examining patient, physician, technological, clinical and health system influences on care management decisions that affect the safety of telediagnosis in primary care.

Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.

Communication and Resolution Programs (CRP) are a promising strategy for managing the aftermath of medical harm. This 18-month collaborative will help participants engage leadership, implement CRP processes, build patient partnerships and establish measurement approaches to gauge the success of CRP efforts. The program will launch in 2022 and applicants will be informed of participation status no later than December 10, 2021.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Bjørn B, Anhøj J, Østergaard M, et al. J Patient Saf. 2021;17:e593-e598.
Trigger tools are used as signals to detect potential adverse events. Using the Institute for Healthcare Improvement Global Trigger Tool (GTT), one patient safety review team was unable to reproduce harm rates in a test-retest reliability study, suggesting the GTT may not be a reliable measure of harm over time. The team recommends additional test-retest studies in other hospitals.
Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11:e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38:1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.
Hussein M, Pavlova M, Ghalwash M, et al. BMC Health Serv Res. 2021;21:1057.
Accreditation programs, such as Magnet Hospital Program and The Joint Commission, are intended to improve hospital patient safety and quality. This review of 76 studies suggests accreditation has a positive impact on safety culture, efficiency and length of stay. Effects on mortality and healthcare-associated infection rates were mixed.
Klimmeck S, Sexton BJ, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47:783-792.
Safety WalkRounds involve health care leadership or managers visiting frontline staff and engaging in discussions about safety concerns. One university hospital in Switzerland combined WalkRounds with structured in-person observations which helped identify safe care practices and deficits in patient safety. However, there were no significant changes in safety and teamwork climate nine-months after implementation.