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National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.  

Rockville, MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Pub. No. 20-0048.

AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2020, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between July 2012 and December 2019. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. This iteration of the chartbook contains an additional 619,111 reports not included in the prior NSPD chartbook.  
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.

Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Vaismoradi M, Vizcaya-Moreno F, Jordan S, et al. Sustainability. 2020;12.
This systematic review identified five articles exploring factors influencing error disclosure and reporting practices by nurses in residential long-term care settings. Nurses were not always willing to disclose errors due to lack of confidence, knowledge and understanding of error disclosure guidance, as well as fear of repercussions, litigation, and loss of trust. Nurse leaders were identified as playing an important role in how incident reports are processed and used for improving safety, and should encourage and support error disclosure.
Taylor DR, Bouttell J, Campbell JN, et al. Int J Qual Health Care. 2020;32.
Used in the United Kingdom, treatment escalation/limitation plans (TELPs; similar to advanced directives and other end-of-life care plans  used in the United States) are intended to minimize harm by setting individualized treatment limits in the event of acute deterioration. This retrospective case-control study set in three UK hospitals explored whether the use of TELPs was associated with reductions in non-beneficial interventions, harms, and complaints about end-of-life care from next of kin. Over a three-year period, 59 complaints were received by the three included hospitals. The authors found patients at end-of-life whose next-of-kin submitted a complaint received poor care (higher rates of non-beneficial interventions and harms) compared to controls. The authors did not identify any difference between complaint cases who did or did not have a TELP.
Becker RE. J Patient Saf. 2020;16.
This commentary explores two scientific cultures in modern medicine. A ‘traditional culture’ leaves error control up to individuals and groups of healthcare practitioners; the author describes how this culture leads to an overconfidence among practitioners about personal abilities to reduce errors. In contrast, a ‘modern scientific culture’ considers errors as inevitable and pervasive throughout medicine and beyond individuals or groups to control. The author describes the competing priorities of these cultures, and suggests that error control efforts in medicine will be more successful if there is a paradigm shift towards a more ‘modern’ attitude.
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Int J Equity Health. 2020;19.
To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.
Schenk EC, Bryant RA, Van Son CR, et al. J Nurs Care Qual. 2019;34:273-278.
This qualitative study asked patients and families to evaluate the feasibility of an advocate to help families speak up about safety concerns in the hospital. Patients and families identified concerns and opportunities that the research team had not previously considered. A past Annual Perspective discussed the many ways patients and families can make their care safer.