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Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17:e821-e828.
Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.

ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.

Delays in diagnosis and treatment during life-threatening emergencies such as strokes can result in irreversible patient harm. This article discusses a variety of factors contributing to errors in administering hypertonic sodium chloride in emergent situations. The piece shares recommendations touching on various elements of the medication delivery process to enhance safety.
Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;30:1002-1009.
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.
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;Epub May 19.
Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.

AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.

Problems in communication are common contributors to patient care mistakes. This toolkit draws from experience with the TeamSTEPPS model to highlight best practices in the use of huddles, debriefs and other teamwork improvement strategies.
Abela G. J Tissue Viability. 2021;30:339-345.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Langevin M, Ward N, Fitzgibbons C, et al. Simul Healthc. 2022;17:e51-e58.
Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of error as well as generate creative strategies for error prevention. In this study, researchers found that simulation can optimize SBEA-generated recommendations and that it provides opportunity to test the intervention in real-life settings before widespread implementation.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Institute for Safe Medication Practices.
These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2022-2023 fellowships has closed.
Urman RD, Seger DL, Fiskio JM, et al. J Patient Saf. 2021;17:e76-e83.
Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. J Nurs Care Qual. 2021;36:327-332.
Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.
Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.
Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting. 

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Lee M, Lee N-J, Seo H-J, et al. West J Nurs Res. 2021;43:972-983.
Patients and families are essential partners in identifying and preventing safety events. In this systematic review, the authors found that information-based interventions (e.g., videos, offline classes) promoting patient and family engagement in patient safety were mostly effective. The effectiveness of interventions involving both information and involvement (e.g., use of decision aids to determine care plan) strategies was inconsistent.  
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Acad Med. 2021;96:75-82.
Quality improvement and patient safety (QIPS) training is increasingly being incorporated into formal medical education. This article describes an integrated framework for QIPS training for internal medicine residents focused on four areas: (1) culture of safety, (2) strategies for investigating events and tracking improvements, (3) reporting and presenting events, and (4) improvement work. This specialty-agnostic framework allows for integration across graduate medical education (GME) specialties and can serve as a model for other institutions.  
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.