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Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
Alexander GL, Madsen RW. J Patient Saf. 2021;17(6):e483-e489.
Information technology (IT) is prevalent across healthcare settings. This study used publicly available nursing home data and a survey on IT sophistication to identify the relationship between nursing home health deficiencies and IT sophistication. Results indicate health deficiencies decreased as IT sophistication increased, suggesting investment in IT could lead to further patient safety benefits in nursing homes.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17(6):e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2021;Epub Aug 20.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Fatima S, Soria S, Esteban- Cruciani N. BMC Med Educ. 2021;21(1):408.
Healthcare providers who are involved in a medical error and feel guilt, remorse, shame, and anger are sometimes referred to as “second victims”. This mixed-methods study surveyed medical residents about their well-being, coping strategies, and support following a self-perceived medical error. Residents reported feeling fear, shame, and feeling judged, and many used maladaptive strategies to cope.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Grundgeiger T, Hurtienne J, Happel O. Hum Factors. 2020;63(5):821-832.
The usability of information technology continues to be a challenge in health care. The authors suggest that consideration of the user is critical to improving interaction with technology and thus increasing patient safety. They provide a theoretical foundation for considering user experience in healthcare.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21(1):1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28(2):188-204.
This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.
Papaioannou AI, Bartziokas K, Hillas G, et al. Postgrad Med. 2021;133(5):524-529.
Incorrect use of medical devices can lead to unfavorable outcomes. In this study of 663 patients with asthma and/or chronic obstructive pulmonary disease (COPD), 41% demonstrated incorrect use of their inhaler. Incorrect use was more common among older patients and associated with more acute exacerbations.
Searns JB, Williams MC, MacBrayne CE, et al. Diagnosis (Berl). 2021;8(3):347-352.
This study leveraged “Great Catches” as part of an existing handshake antimicrobial stewardship program (HS-ASP) to identify potential diagnostic errors. Using a validated tool, researchers found that 12% of “Great Catch” cases involved diagnostic error. These cases included a diagnostic recommendation from the HS-ASP team (e.g., recommendations to consider alternative diagnoses, request additional testing, or additional interpretation of laboratory results). As these diagnostic recommendations often flagged diagnostic errors, this suggests that the HS-ASP model can be leveraged to identify and intervene on diagnostic errors in real time.
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Res Social Adm Pharm. 2021;17(8):1426-1432.
This multicenter prospective study explored the effect of medication reconciliation on patient-reported, potential adverse events post-discharge. Although the intervention – which consisted of a pharmacy team providing patient both education and medication review upon admission and discharge as well as information transfer to primary care – did not decrease the proportion of patients with adverse events, it did reduce the number of potential adverse events.
Wang M, Dewing J. J Nurs Manag. 2021;29(5):878-889.
Nursing leadership plays an important role in safety culture. This literature review found evidence of mediating effects between nursing leadership and a decrease in adverse patient outcomes. The authors conclude that mangers should emphasize workplace empowerment, leader-nurse relationship and the quality of the care environment as part of an effective workplace culture.

ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5. 

Error reporting is an essential contributor to system safety improvement. This article examines weaknesses in error reporting behaviors, characteristics of organizations and technologies that facilitate underreporting and ineffective report analysis. The piece shares recommendations to enhance adverse event reporting to support learning.
Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47(9):604-607.
Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.

American Association for Physician Leadership. October 30-31, 2021.

Attaining high reliability remains a challenge throughout health care. This virtual session will focus on human error, safety culture, system thinking, and leadership as primary concepts driving progress toward reliable healthcare delivery.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.
Churruca K, Ellis LA, Pomare C, et al. BMJ Open. 2021;11(7):e043982.
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;Epub Jul 27.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.