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Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40(10):1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
Aasen L, Johannessen A‐K, Ruud Knutsen I, et al. J Clin Nurs. 2021;Epub Sep 28.
Patients receiving hospital-level care at home (hospital-at-home, (HAH) have fewer complications, better patient and family satisfaction, and better outcomes. This study describes nurses’ and physicians’ perspectives of pediatric HAH. Three themes evolved: building a trusting relationship with the child and family; performing essential skills; and acting as the “hub” between families and providers.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17(7):e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
Breuker C, Macioce V, Mura T, et al. J Patient Saf. 2021;17(7):e645-e652.
In this prospective observational study, hospital pharmacy staff obtained the best possible medication history for adult patients at admission to and discharge from one French hospital. Unintended medication discrepancies were identified in nearly 30% of patients. Most medication errors were omissions and risk of error increased with the number of medications.
Budnitz DS, Shehab N, Lovegrove MC, et al. JAMA. 2021;326(13):1299.
Previous studies have utilized data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project (NEISS) to analyze harms from medication use. This study uses updated NEISS data to also describe harms from nontherapeutic medication use. Visits to emergency departments for medication adverse events varied by age group, medication class, and intent of use.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71(708):e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.
Griffin JA, Carr K, Bersani K, et al. Diagnosis (Berl). 2021;Epub Aug 23.
Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.
James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.
Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.
Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21(1):1038.
Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6(5):e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.
Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
Fostering a positive safety culture is essential to delivery of safe care. This mixed-methods study of nurses and non-physician health professionals found that staff perceptions of senior leadership, teamwork, and turnover intention were significantly associated with overall patient safety grade.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

American College of Emergency Physicians, National Association of Emergency Medical ServicesAnn Emerg Med. 2021;78(3):e37-e57. 

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.

Patient Safety Movement. October 29, 2021. 

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar discussed how different stakeholders might view approaches to medical error management. It described how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.
Drug Enforcement Administration. October 23, 2021.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers.