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Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

The APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.

Bias in any form degrades the safety and effectiveness of communication and care. This report summarizes data documenting the impact of racial and ethnic discrimination on older adult patients. It provides recommendations that include increasing content in medical school curriculum to raise awareness of biased medical care and tailoring communication needs to ethnic communities as steps toward reducing discrimination.
American Society for Healthcare Risk Management. Chicago, IL: July 11-16 2022.
This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
Organization: American Society for Healthcare Risk Management (ASHRM)
Event Description: This four-day in-person conference hosted by ASHRM will hold sessions that highlight models and strategies that risk managers and patient safety professionals can apply within their organizations to work towards the shared goal of advancing safe and trusted health care. There is also as an opportunity to complete one of ASHRM's certificate programs, such as the Patient Safety Certificate, as part of their pre-conference activities.
Event Location: In Person: Boston, MA
Date: In-person: September 11 - 14, 2022
Event Fee: Fee Associated
CE or CME Offered? No
AORN J. 2022;115:454-457.
This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize.

Beed M, Hussain S, Woodier N, et al. J Patient Saf. 2022;18:e652-e657.
Critical incident reporting is an important method to detect patient safety hazards and improve care. A research team in one large UK tertiary hospital reviewed cardiac arrest calls and cardiopulmonary resuscitation (CPR) events reported to the hospital incident reporting system; ten thematic areas for potential improvement were identified (e.g., failure to rescue, staffing concerns, equipment/drug concerns). Organizations could replicate this longitudinal process to improve high-risk patient safety event outcomes.
Fischer SH, Shih RA, McMullen TL, et al. J Am Geriatr Soc. 2022;70:1047-1056.
Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process. 
Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.
Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.
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. 

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).
Essex R, Weldon SM. Nurs Ethics. 2022;Epub Apr 12.
Appropriate staffing levels have been shown to impact patient safety and patient outcomes. This review of literature on healthcare worker strikes explores potential negative impacts, such as compromised patient safety due to decreased staffing levels, and justifications, such as long-term benefits.