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Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is part of a publication series examining diagnostic improvement across health care.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.

Challenges beset safe care delivery for indigenous peoples. This report examines factors contributing to adverse events in this patient population. Recommendations for improvement include an emphasis on harm monitoring and incident reporting. A related report examines the lack of application of maternity best practices in the Indian Health Service.

de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.

The assessment of patient safety culture is critical for understanding the success of organizational efforts to provide a foundation for improvement work. This report examines tools used in a variety of countries to assess culture and underscores the value that the assessment of culture can bring to understanding problems and implementing sustainable improvements.

Public Health England. London, UK: Crown Copyright; 2020.

The COVID-19 pandemic has revealed weaknesses in health care systems worldwide that have affected drug distribution, worker safety and health equity. This report provides a stakeholder analysis of societal conditions affecting patients with coronavirus in the United Kingdom. The authors conclude that racism and discrimination must be considered to correct inequities that impact safe care for Black Asian Minority Ethnic (BAME) patients to effectively respond to COVID-19.    

Singh H, Bradford A, Goeschel C. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. AHRQ Publication No. 20-0040-1-EF.

This issue brief discusses a sociotechnical approach to understanding safe diagnosis and the range of data sources required for the follow-up and tracking of diagnostic information. The publication recommends a strategy to support health care organizations in identifying and beginning to measure diagnostic error to enable learning. This issue brief is the first in a series on diagnostic safety.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.

Famolaro T, Hare R, Thornton S, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0016.

The latest publication from the Agency for Healthcare Research and Quality (AHRQ) reports results of 282 ambulatory surgery centers (ASC) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. The majority of respondents (86%) rated their organization’s overall safety rating as excellent or very good.

Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019.

This brief evaluated published accounts of frameworks for implementing high reliability organizations to examine which approaches have been most successful. The analysis identified five common implementation strategies: leadership development, data system utilization, quality improvement interventions, training and learning, and safety culture.

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role. 
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Keen J, Nicklin E, Wickramasekera N, et al. BMJ Open. 2018;8.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Agency for Healthcare Research and Quality; AHRQ.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. 2017;5.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.