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Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17:473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
Grabinski ZG, Babineau J, Jamal N, et al. Jt Comm J Qual Patient Saf. 2021;47:731-738.
Incident reporting and analysis can lead to improvements in patient safety. This study analyzed incident reports regarding unsafe conditions (UC) in one academic women and children’s hospital. The majority of UCs were equipment and medication issues, and most had one or more contributing factors.

Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17: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.

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.
Prabhu V, Mikhly M, Chung R, et al. Am J Med Qual. 2022;37:72-80.
Encouraging adverse event reporting among clinicians, including medical trainees, is essential to improving patient safety. This hospital implemented a multi-pronged intervention – using a combination of branding, education and outreach, and feedback – to increase patient safety event reporting by house staff. The intervention led to increased event reporting in the short- and long-term.

Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.
Berry P. Postgrad Med J. 2021;97:695-700.
Staff willingness to speak up about patient safety enables organizations to implement improvements to prevent patient harm. The author describes barriers that trainees face when presented with an opportunity to speak up as well as barriers faced by those who receive the reports. Initiatives to improve trainee speaking up behavior are discussed.
Lalani C, Kunwar EM, Kinard M, et al. JAMA Intern Med. 2021;181:1217-1223.
Medical device-associated errors are common and often result in preventable patient harm. Based on medical device adverse event data reported to the FDA, this study used natural language processing to identify events not classified as deaths even though the patient died. Findings suggest that approximately 17% of medical device events that resulted in death were classified in other categories.

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Khan NF, Booth HP, Myles P, et al. BMC Health Serv Res. 2021;21.
This study assessed how and when quality improvement (QI) feedback reports on prescribing safety are used in one general practice in the UK. Four themes were identified: receiving the report, facilitators and barriers to acting upon the report, acting upon the report, and how the report contributes to a quality culture. Facilitators included effective dissemination of reports while barriers included lack of time to act upon the reports. As most practitioners indicated the QI reports were useful, efforts should be made to address barriers to acting upon the reports.
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.
Nestler DM, Laack TA, Scanlan-Hanson L, et al. Jt Comm J Qual Patient Saf. 2021;47:503-509.
Peer review can provide clinicians an opportunity to learn from failure, but the process has yet to be standardized.  This article describes the development and implementation of an evidence-based, structured, reproducible care review system at one emergency department affiliated with an academic hospital. The authors outline the care review process, which includes direct care staff feedback; single provider and peer review; structured case rating; systems analysis; loop closure; practice and education output; and consideration of psychological safety.
Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17:282-289.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.
Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.
Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.