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Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21:842.
The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18:7581.
Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26:64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
Paradis KC, Naheedy KW, Matuszak MM, et al. Pract Radiat Oncol. 2020;11:e106-e113.
Assessing risk and learning from adverse events are core components of patient safety improvement. The authors propose a method which leverages a radiation oncology incident learning system with a simplified failure mode and effects analysis (FMEA) to analyze safety events and monitor the success of workflow changes to improve patient safety and address high-risk errors.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.

 A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR).

Ahlberg E-L, Elfström J, Borgstedt MR, et al. J Patient Saf. 2020;16:264-268.
Incident reporting systems and root cause analyses are the primary mechanisms by which adverse events are identified and reviewed. This analysis of incident reports occurring at one hospital in Sweden found that the handling, causes, and actions taken to prevent recurrence of injuries were similar across three severity levels (injuries leading to deaths, permanent harm, or temporary harm). However, the feedback generated based on these reports was primarily used at the department level and did not lead to organizational learning.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning. 
Veazie S, Peterson K, Bourne D, et al. J Patient Saf. 2022;18:e320-e328.
This review expands upon previous work evaluating implementation strategies for high-reliability organizations. Review findings indicate that health care system adoption of high-reliability principles is associated with improved outcomes, but the level of evidence is low. Future research should include concurrent control groups to minimize bias and focus on whether certain high-reliability frameworks, metrics, or intervention components lead to greater improvements.  
Liberati EG, Tarrant C, Willars J, et al. BMJ Qual Saf. 2021;30:444-456.
Maternal harm is a sentinel event and improving maternal safety is receiving increased attention in both policy and clinical settings. The researchers used qualitative methods to generate a new plain language framework identifying safe behaviors and practices in inpatient maternity units. Several synergistic features were identified including a commitment to safety culture; technical competence; teamwork, cooperation, and positive working relationships.  

Alemi F ed. Special Section: Event Analysis and Risk Management. Qual Manag Health Care. 2020;29(4):232-278.

Adverse event analysis is core for organizational learning from poor performance. This special section discusses how examination tools such as failure mode and effect analysis and root cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement.

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Boston, MA: Institute for Healthcare Improvement: September 2020.  

This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.  
de Kam D, Kok J, Grit K, et al. Health Policy (New York). 2020;124:834-841.
Using qualitative and quantitative data, this study evaluated how incident reporting systems in the Netherlands contribute to organizational learning. The authors identified five core areas related to incident reporting: (1) changed staff attitudes and increased reporting; (2) improved sentinel event investigations; (3) participative learning; (4) local learning, and; (5) recommendations that improve care quality and safety.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
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.
Myers LC, Gartland RM, Skillings J, et al. Acad Med. 2020;95:1215-1222.
This case-control study using medical malpractice claims identified patient-, provider-, and claim-related factors in claims directly involving physician trainees in the events. The majority of claims were procedure-related and the most common diagnosis in claims cases was puncture or laceration during surgery. Inadequate supervision was a common contributing factor.