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Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.
Grytnes R, Nielsen ML, Jørgensen A, et al. Safety Sci. 2021;143:105417.
Safe workplaces, and employees who work safely, are an important component of patient safety. This study explores new employees’ safety learning in three sectors, including care of older adults. Organizational and informal safety training and learning are discussed.
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25:17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses may help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20:134.
A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.
Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Van Eerd D, D'Elia T, Ferron EM, et al. J Safety Res. 2021;78:9-18.
Working conditions for healthcare workers can affect patient safety. Conducted at four long-term care facilities in Canada, this study found that a participatory organizational change program can have positive impacts on identifying and reducing musculoskeletal disorder hazards for employees, including slips, trips, falls, and ergonomic hazards. Key factors for successful implementation of the change program include frontline staff involvement/engagement, support from management, and training.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.
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.
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.
Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17:e448-e454.
Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.

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.

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.
Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19:s14-s26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.  
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.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.