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California Hospital Patient Safety Organization. Sacramento, CA; 2021.

Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2020 trends, activities, and outcomes of initiatives at a 21-state PSO. Sections of the report include high-level review of reported medication events, safe table data analysis, and strategies to improve data quality.

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Maternal Safety

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

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Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.

Just Culture, Medication Error Prevention, and Second Victim Support: a Better Prescription for Preparing Nursing Students for Practices.

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Jones J, Treiber L, Shabo R, et al. Kennesaw, GA: WellStar School of Nursing, WellStar College of Health and Human Services, Kennesaw State University; 2021.

Medication administration practice is a foundational element of nursing education, yet the emphasis on safety is lacking. This report discusses gaps in some nursing programs that detract from building safe medication skills in nurses. Curriculum weaknesses discussed include punitive orientation to nursing student medication errors, lack of error prevention instruction, and insufficient opportunities for competency development to support peers that make mistakes.

Transforming Education on Diagnostic Reasoning: Ready, Set, Go!

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Evanston, IL: Society to Improve Diagnosis in Medicine; May 2021.

Reasoning improvement is a recognized strategy for reducing misdiagnosis. This report describes an educational intervention for use in a variety of care environments that rest on collaboration and teamwork as core tenets to enhance diagnostic reasoning.

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

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Washington DC: Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

Medical Office Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

Nebraska Coalition for Patient Safety Annual Report.

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Omaha, NE: Nebraska Coalition for Patient Safety; 2021.

Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected between 2008 and 2020, offers insights drawn from an analysis of 1193 incident reports..

Surveys on Patient Safety Culture(TM) (SOPS®) Hospital Survey 2021 User Database Reports.

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Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2021. AHRQ Publications Nos. 21-0016(1.0) and 21-0017(2.0).

Establishing culture of safety is an essential component to develop high reliability organizations and ensure patient safety. The AHRQ Hospital Survey on Patient Safety Culture is a validated survey that examines organizational perceptions about safety culture ranging from communication about errors to teamwork within and across units. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The 2021 SOPS Hospital 1.0 Database Report includes 320 hospitals and 191,977 respondents, and the 2.0 Database Report includes 172 hospitals and 87,856 respondents. In both reports, areas of strength included teamwork within units and leadership, and respondents reported concerns about handoffs and transitions. The 1.0 Database Report also noted concerns about leadership expectations and actions for promoting safety, and the 2.0 Database Report noted concerns about staffing and work pace.

Organizational Evidence-Based and Promising Practices for Improving Clinician Well-Being.

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Sinsky CA, Biddison LD, Mallick A, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2020.

Clinician well-being is determined by system characteristics that support patient safety. This perspective suggests six areas of organizational focus to improve clinician well-being and resiliency including assessment, leadership, and support mechanisms.

Special Section: Event Analysis and Risk Management.

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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.

System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation.

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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.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

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London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Safer Together: A National Action Plan to Advance Patient Safety.

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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.

The Guide for Hospital and Health System Leaders for Diagnostic Quality and Safety.

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Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.

Patients and families provide unique insights for leaders working to improve diagnosis. This report highlights how organizations can best implement patient advisory council programs to spark learning, enhance feedback, and support a safety culture that enhances the impact of those efforts.

Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries.

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de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.

The assessment of patient safety culture is critical for understanding the success of organizational efforts to provide a foundation for improvement work. This report examines tools used in a variety of countries to assess culture and underscores the value that the assessment of culture can bring to understanding problems and implementing sustainable improvements.

The threat within: mitigating the risk of medical error.

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Bennett S. Springer International Publishing; 2020.

Despite efforts to protect patients, harm still occurs during the course of medical care. This book chapter highlights how proactive risk mitigation can reduce opportunities for preventable patient harm. The author reviews tools to reduce the potential for failure used by commercial aviation and how they could be used in health care.

National Patient Safety Syllabus 1.0 Training for all NHS staff.

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Colleges A of MR. London, UK: Academy of Medical Royal Colleges; 2020.

A foundational understanding of safety is core to building reliable care processes and teams. This report outlines a curriculum that was developed in response to a national improvement strategy for National Health Service staff. The training program highlights the themes of the systems approach, risk competencies, human factors and safety culture as linking content domains together to develop safe practitioners.

Actionable Patient Safety Solutions (APSS): Creating a Foundation for Safe and Reliable Care

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Irvine, CA: The Patient Safety Movement; 2020.

Patient safety success requires leadership, resources, and a strategic approach. This publication shares a model for improvement that involves developing a safety culture, a system-focused framework, and plan to sustain the effort.

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