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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.
Goh HS, Tan V, Chang J, et al. J Nurs Care Qual. 2021;36:e63-e68.
Incident reporting systems are a common method for hospitals to detect patient safety events, but prior research has questioned whether these systems improve outcomes. Conducted in a nursing home, this study found that an existing incident reporting system redesigned to facilitate double-loop learning could improve nurses’ patient safety awareness and workplace practices, which could improve patient outcomes and safety.

Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
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.  
Quach ED, Kazis LE, Zhao S, et al. J Am Med Dir Assoc. 2021;22:388-392.
This cross-sectional study examined the impact of safety climate on adverse events occurring in Veterans Administration (VA) nursing homes and community living centers. Survey results suggest that nursing homes may reduce adverse events by increasing supportive supervision and a safer physical environment. The survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls and catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls, and catheter use.
Huetteman E. Kaiser Health News. 2020;August 12.
Health care workers are known to work while unwell due to stigma, commitment, and personal finances. This article discusses presenteeism in the context of the COVID-19 pandemic. It discusses challenges for individuals who feel organizational pressure to return to work despite health concerns for themselves, their families, and their patients.   
Klest B, Smith CP, May C, et al. Psychol Trauma. 2020;12:S159-S161.
Institutional betrayal occurs when a patient (or other individual) experiences a harm and the (health) systems compound that harm by failing to support or believe the patient. The authors of this commentary reflect on institutional betrayal during the COVID-19 pandemic and discuss examples of betrayal experienced by patients, family members, and medical providers.

Cambridge, MA; CRICO Strategies: July 14, 2020.

Malpractice claims can generate data that informs safety efforts. This webinar discussed one large health system’s professional liability claim analysis and the factors contributing to indemnity payments. The session reviewed how examining liability results can proactively focus organizational training and improvement initiatives.
Farag A, Vogelsmeier A, Knox K, et al. J Gerontol Nurs. 2020;46.
Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive model assessing nurses’ willingness to report medication near-misses. On a scale from 0 to 3 (where high scores indicate more willingness to report) the mean score of nurses’ willingness to report near-miss incidents was 1.79. The model predicted a 19% variance in willingness to report. The strongest predictors of willingness to report were non-punitive safety climate, transformational leadership, trusting relationships with nurse managers, and familiarity with the reporting system. The authors conclude that social and system factors are necessary to improve nurses’ voluntary reporting of medication near-misses.
Barba V, Foreman K, Robey K. Int J Healthc Manag. 2021;14:926-932.
This article describes the efforts towards high reliability undertaken by one specialty hospital for medically complex children and adults with intellectual and development disabilities. The organization employed a multi-pronged, data-driven approach involving training and education in quality management and patient safety and principles of high reliability organizations. Improvements in medication errors and hospital-acquired pressure injuries were observed, but employee engagement survey results reflect concern among staff that an emphasis on data may detract from patient care. 
Prang IW, Jelsness-Jørgensen L-P. Geriatr Nurs. 2014;35:441-447.
In this qualitative study, nursing staff in long-term care facilities described barriers to reporting patient safety problems, including lack of a supportive culture, insufficient time, and fear of conflict or repercussions. These findings highlight the need for multifaceted interventions to improve nursing home safety.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.

Smedley BD, Stith AY, Nelson AR, eds and Institute of Medicine. Washington, DC; The National Academies Press: 2003. ISBN 9780309082655.

Patient race and socioeconomic disparities result in biases that affect patient safety. This publication examines strategies to minimize these impacts such as interpreter use, localized care delivery, and improved data collection to better ascertain the true state of the problem and design initiatives to address it.