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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.
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.
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.
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.

Northwest Safety and Quality Partnership. June 22, 2021. 

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

Gandhi TK. NEJM Catalyst. Epub 2021 May 27.

The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author advocates using the same strategies to reduce inequities that were used to improve patient safety: 1) culture, leadership, and governance; 2) learning systems; 3) workforce; and 4) patient engagement.
Brockett-Walker C, Lall M, Evans DD, et al. Adv Emerg Nurs J. 2021;43:89-101.
This review critiques a 2016 article (link below) which found unconscious, implicit bias can negatively impact patient care when emergency department providers are under increased cognitive stress. The authors propose strategies for educators and institutions to combat implicit bias including self-awareness, stress reduction, and respectful communication.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
Jt Comm J Qual Patient Saf. 2021;47:394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.
Thompson R, Kusy M. Nurs Adm Q. 2021;45:135-141.
Effective leadership is essential to team performance and organizational safety. This article discusses the role of team leaders on team performance during the COVID-19 pandemic. The authors review common mistakes made during the pandemic (such as broken trust or ignoring disruptive behaviors) and lessons learned to help build strong, cohesive teams.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147:e20200031.
Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.
Minehart RD, Bryant AS, Jackson J, et al. Obstet Gynecol Clin North Am. 2021;48:31-51.
Improving maternal safety and reducing disparities in maternal morbidity and mortality are national priorities. This article discusses inequities in maternal health outcomes and provision of care, factors involved in the relationship between race and health (e.g., racism, social status, health behaviors), and efforts at the national-, state-, and hospital-level to improve obstetric care and outcomes for Black mothers.

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.
Capers Q, Bond DA, Nori US. Chest. 2020;158:2688-2694.
Implicit and explicit bias can reduce the effectiveness and safety of care. Using four case studies, this article highlights how healthcare professionals can be influenced by biases, how these biases threaten patient safety, and strategies to mitigate biases and attenuate the impact of bias and racism on patient outcomes.