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Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.
Acorda DE, Bracken J, Abela K, et al. Jt Comm J Qual Patient Saf. 2022;48:196-204.
Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements. 

Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.
Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;Epub Apr 4.
Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients.  Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.
Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;Epub Mar 4.
Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).1 Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.

Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Kukielka E, Jones R. Patient Safety. 2022;4:49-59.
Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.

March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.

Transitions of care from inpatient to outpatient settings are vulnerable to medication errors. This study found that patients receiving pharmacist-led medication reconciliation and education prior to discharge reported higher patient satisfaction scores; lower readmission rates compared to standard care patients were also observed. Pharmacists potentially prevented 143 medication safety events during medication reconciliation.
LaScala EC, Monroe AK, Hall GA, et al. Pediatr Emerg Care. 2022;38:e387-e392.
Several factors contribute to pediatric antibiotic medication errors in the emergency department, such as the frequent use of verbal orders and the need for  weight-based dosing. Results of this study align with previous research and reinforce the need for further investigation and interventions to reduce antibiotic medication errors such as computerized provider order entry.
Huang C, Barwise A, Soleimani J, et al. J Patient Saf. 2022;18:e454-e462.
Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic error played a part in rapid response team activations or unplanned admissions to the intensive care unit. Clinicians reported that 18% of acute care patients experienced diagnostic errors.

Katz MJ, Tamma PD, Cosgrove SE, et al. JAMA Netw Open. 2022;5(2):e220181.

Overuse of antibiotics has been common in nursing homes; therefore, antibiotic stewardship programs (ASPs) have been emphasized by experts. To assist facilities, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use developed programs and a toolkit to improve the appropriate use of antibiotics. This quality improvement program found that a focused educational initiative to establish ASPs in nursing homes was associated with reduction in antibiotic use in those facilities with high levels of engagement.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Hasselblad M, Morrison J, Kleinpell R, et al. BMJ Open Qual. 2022;11:e001315.
Disruptive patient behaviors in the hospital not only pose a risk to staff safety, but may also experience patient safety risks such as misdiagnosis. A behavioral intervention team (BIT) was deployed on two adult medical-surgical wards to evaluate the effectiveness of an intensive behavioral management intervention. While there were no differences in the number of behavioral issues reported in the intervention or control group, nurses rated BIT as the most beneficial support to manage patients exhibiting disruptive behaviors.

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.

Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. This project will support the implementation of targeted hospital-acquired infection prevention initiatives building on the Comprehensive Unit-based Safety Program (CUSP) concept. The cohort that is focused on intensive care units and acute care is currently recruiting participants. Cohorts devoted to surgical services and long-term care will begin enrolling members later in 2022.
Dionisi S, Di Simone E, Liquori G, et al. Public Health Nurs. 2022;39:876-897.
Causes of medication errors occurring in home care may differ from those in the hospital setting. This systematic review identified three main risk factors for medication errors in the home: transition documentation, medication reconciliation, and communication among the multidisciplinary team. Most studies recommend involvement of a pharmacist as a member of the care team.