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O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33:mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.

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.
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.  
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.
Madden C, Lydon S, O’Dowd E, et al. J Patient Saf. 2022;18:e51-e60.
Patient engagement has been recognized as a National Patient Safety Goal, and patients play a key role in ensuring safety in health care. This systematic review discusses 31 different patient-reported safety climate measures addressing items such as patient-centered care, health care costs, and comfort. The authors note that few measures report satisfactory validity and reliability, and few measures have had systematic usability testing. They suggest that future research focus on developing a stand-alone measure with high validity and reliability, and assess core safety climate domains from a patient perspective with an emphasis in primary care.
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.
Müller BS, Donner-Banzhoff N, Beyer M, et al. BMC Fam Pract. 2020;21.
Healthcare providers may feel regret when the care they provide falls short of expectations. This qualitative study solicited experiences from 29 German primary care providers about diagnostic errors resulting in delayed care or harm. In nearly all cases (26/29) the final diagnosis was more serious than the original diagnosis and one-third resulted in preventable harm to patients (e.g., regular blood glucose tests may have prevented a stroke that likely occurred due to decompensated diabetes under steroids).  Regardless whether the diagnostic error resulted in patient harm, the vast majority (27/29) of providers expressed feelings of regret, highlighting the need for peer-support to deal with the emotional impact of incorrect diagnostic decisions.
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.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Lorincz CY, Drazen E, Sokol PE, et al. Chicago, IL: American Medical Association; 2011.
Although traditionally the majority of patient safety efforts have focused on inpatient care, the overwhelming bulk of health care actually takes place in the ambulatory setting. Accordingly, the scope of widespread documented adverse events among outpatients is vast. Updating a previous report, this publication analyzes efforts to improve patient safety in ambulatory care over the past decade and identifies gaps that future research should address. Dr. Richard Baron discusses patient safety in the office setting in an AHRQ WebM&M perspective.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005.
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine’s report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.