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Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;61:761-771.
Patient safety concerns in community pharmacies have been documented in the media. This study sought to examine the association of working conditions and patient safety. Results indicate that while all participants reported negative company climate and workflow, those in chain pharmacies reported significantly more fear of speaking up about patient safety issues than those in independent, big box, or grocery pharmacies.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138:229-235.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

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.

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur. 
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.   
ISMP Medication Safety Alert! Acute Care Edition. 2020;25.
Successful development of a just culture centers on understanding different types of flawed human behavior and designing effective organizational responses to these failures. This article compares human error, at-risk behavior, and reckless behavior to suggest systems design changes for patient safety programs to generate opportunities for improvement.  
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  
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.
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Monsees E, Goldman J, Vogelsmeier A, et al. Am J Infect Control. 2020.
There is a scarcity of literature on the role nurses play in antibiotic stewardship (AS). This article describes the results of a multisite survey of nurse perceptions of AS practices. Statistical analyses of 558 survey responses indicate that nurses identify with their role in AS processes but believe hospital safety culture inhibits their work in this area.
Rein L. Washington Post. October 5, 2019.
The Veterans Affairs health system is challenged by process and quality concerns that contribute to preventable patient harm. This story examines how trends in deaths at a VA medical center were slow to raise concerns, what exacerbated the lack of action, and what is being done to address the problems. 
Durham ML, Jankiewicz A. J Patient Saf. 2019;15:181-183.
Considerable effort has been devoted to optimizing methods of detecting errors and safety hazards in health care. This article highlights use of the Framework for Safe, Reliable, and Effective Care to help nurses address medication administration errors.
Patel MR, Friese CR, Mendelsohn-Victor K, et al. J Oncol Pract. 2019;15:e529-e536.
Although electronic health records have addressed some patient safety concerns, they have also introduced new risks. In this survey study in oncology, nearly 300 individuals, including physicians, nurse practitioners, and nurses, completed a survey ranking their practice's reliance on the electronic health record (from 1= "all paper" to 5= "all electronic") and measuring safety culture and quality of clinician–clinician communication. Investigators found that individuals describing a greater degree of electronic health record use reported lower safety culture scores, and individuals who rated communication higher also perceived safety culture as more optimal. The authors suggest that challenges to electronic health record use may affect oncology practitioners' perceptions of safety. A previous PSNet interview discussed the role of health information technology in patient safety.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.