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Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18(9):1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
Silverglow A, Johansson L, Lidén E, et al. Scand J Caring Sci. 2021;Epub Aug 24.
Home care settings harbor unique patient safety challenges. This qualitative study identified three themes regarding care providers’ perceptions of providing safe care for frail older adults living at home – the role of the encounter and interaction, the responsibility of the caregiver, and the threat of insufficient organizational resources.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.
Braverman A. Nurs Manage. 2021;52(9):30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
American Society for Healthcare Risk Management. Louisville, KY, April 4-9, 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.
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56(5):885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30(5):365-374.
The Joint Commission implemented medication management titration standards in 2017, with revisions in 2020. Researchers surveyed critical care nurses about their experiences with medication titration, use of clinical judgment when titrating, nurses’ scope and autonomy, and their moral distress. Of 781 respondents, 80% perceived the titration standards caused delays in patient care and 68% reported suboptimal care, both of which significantly and strongly predicted moral distress.
Svensson J. J Patient Saf. 2021;Epub Aug 5.
Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance – (1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerized methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence, and falls.
Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.
The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.

Kelen GD, Wolfe R, D’Onofrio G, et al. NEJM Catalyst. Epub 2021 Sep 28.

Emergency department (ED) overcrowding and boarding can result in worse patient outcomes and increased risk of medical errors. This article describes several causes and impacts of ED overcrowding, current solutions, and regulatory and institutional-level actions to reduce ED overcrowding.
Iqbal AR, Parau CA, Kazi S, et al. Jt Comm J Qual Patient Saf. 2021;47(12):793-801.
The electronic medication administration record (eMAR) is one technologic strategy to improve medication safety. In this study, usability issues related to eMAR contributed to 473 patient safety event reports. Eight usability challenge categories were identified (e.g. alerts and interoperability). Among these usability challenges, special attention should be paid to workflow and display/visual clutter.
Molina RL, Benski A-C, Bobanski L, et al. Implement Sci Commun. 2021;2(1):76.
Checklists are widely used to improve patient safety, including reductions in catheter-related bloodstream infections and surgical morbidity and mortality. This study focuses on implementation of the 2015 World Health Organization Safe Childbirth Checklist (SCC) which aims to prevent maternal and neonatal morbidity and mortality. Twenty-nine participants from fifteen countries with SCC experience completed a survey and twelve were interviewed. Most reported adapting the SCC for their local setting and a wide variety of implementation strategies were used.
O’Dowd E, Lydon S, Lambe KA, et al. Fam Pract. 2021;Epub Sep 20.
Patient complaints can identify opportunities for patient safety improvement. This study explored whether an existing tool for measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool – can effectively analyze complaints specific to general practice. Key issues identified by the study involved relationships (e.g., communication, patient rights) as well as clinical and management issues.
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;Epub Oct 20.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Schiff G, Shojania KG. BMJ Qual Saf. 2021;Epub Oct 10.
This commentary discusses Dr. Lucian Leape’s new book and highlights the ongoing challenges to sustained quantifiable progress to improving patient safety, including misguided metrics, equipment design issues, persistence of fear and blame culture, burnout and shortages of nurses, primary care and other essential workers.
Schlichtig K, Dürr P, Dörje F, et al. Clin Pharmacol Ther. 2021;110(4):1075-1086.
Building on prior research, this study found that medication errors are common in patients starting new oral anticancer therapy. Nearly two-thirds of these medication errors involved concomitantly administered medications (e.g., other prescribed drugs, over-the-counter medications).