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Organization: Duke University Health System Patient Safety Center
Event Description: This one or two year long series covers the science of well-being and the practical tools and strategies practitioners can use to emotionally support themselves and their team, department, unit, or organization.
Event Location: Online
Date: Various Dates
Event Fee: Fee Associated
CE or CME Offered?
Organization: American Society for Healthcare Risk Management (ASHRM)
Event Description: These in-depth live webinars will cover clinical/patient safety, legal/regulatory, enterprise risk management (ERM), risk financing and more. Each webinar is 1 hour in length and eligible for 1 CE credit towards your CPHRM Certification.
Event Location: Online
Date: On Demand
Event Fee: Fee Associated
CE or CME Offered? Yes
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Blum MR, Sallevelt B, Spinewine A, et al. BMJ. 2021;374:n1585.
Older adults with multimorbidity and polypharmacy are at increased risk of adverse drug events. This cluster randomized controlled trial compared drug-related hospitalization rates of older adults who received a structured deprescribing intervention and those who received usual care. While rates of polypharmacy decreased, there was no effect on drug-related hospitalizations.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8(Suppl1):100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.
Levy FH, Conrad KA, Kemper C, et al. Pediatr Qual Saf. 2021;6(4):e449.
Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the United States. This article describes the development of the Child Health PSO and how it evolved into a learning network through alignment around a common goal, collaboration, and information sharing with high levels of engagement from participating children’s hospitals.

Geneva: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity
Bryant J, Carey M, Sanson-Fisher R, et al. J Patient Saf. 2021;17(5):e387-e392.
When an error or adverse event occurs, patients and families want to be informed. In this study of oncology patients, more than one quarter perceived an adverse event had occurred. While most were informed soon after the event occurred and given an explanation, fewer than half were given information on how to move forward with a complaint if they wished. Regular communication between patients and providers about actual or perceived adverse events may decrease the risk of it happening again.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18(14):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.
Rocha HM, Farre AGM, Santana Filho VJ. J Nurs Scholarsh. 2021;53(4):458-467.
Patient boarding in the emergency department (ED) can result in patient harm. This review explored the association between boarding in the ED and quality of care, outcomes, and adverse events. Increased boarding time was associated with poorer quality of care and outcomes.
Hackenberg EAM, Sallinen V, Handolin L, et al. J Interpers Violence. 2021;36(15-16):7832-7854.
Victims of intimate partner violence (IPV) may seek care at emergency departments. This study of self-reporting IPV victims found that while serious injuries were rare, many victims had suffered extreme violence and approximately half had risk factors for re-abuse. Fewer than 20% were referred to victim advocacy resources.
Hernández-Prats C, López-Pintor E, Lumbreras B. Res Social Adm Pharm. 2021;Epub Jul 12.
Clinical pharmacists play an important role in ensuring patient safety, particularly in interventions aimed at reducing polypharmacy. This review focused on interventions involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure. Findings indicate interventions are most successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure medications are followed.
Jun J, Ojemeni MM, Kalamani R, et al. Int J Nurs Stud. 2021;119:103933.
Burnout among nurses can compromise safe patient care and lead to poor outcomes. This systematic review identified five organizational-level outcomes associated with nurse burnout – (1) patient safety, (2) quality of care, (3) nurses’ organizational commitment, (4) nurse productivity, and (5) patient satisfaction – and these themes were consistently inversely associated with outcome measures.
Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2021;Epub Jul 19.
Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.
Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. J Am Coll Radiol. 2021;18(10):1384-1393.
Delayed diagnosis and treatment of breast cancer can lead to poor outcomes. Based on multi-year data from one health system, the authors of this cohort study found that black women with screen-detected breast cancers were more likely than white women to experience diagnostic delays, including delays in diagnostic evaluation and biopsy. The delay in diagnosis was also associated with an increase in breast cancer mortality.
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17(5):e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Sullivant SA, Brookstein D, Camerer M, et al. Jt Comm J Qual Patient Saf. 2021;47(8):496-502.
Improving screening for suicidal ideation is an important patient safety priority. This article describes the implementation and evaluation of a hospital-wide program to identify teenagers at elevated risk for suicide and to connect them with services. During the first year of implementation, over 138,000 screenings were completed and 6.8% of screens were positive for elevated risk.
Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35(3):258-265.
Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.