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Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51:520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
Kruse CS, Mileski M, Syal R, et al. Technol Health Care. 2020;29:1-14.
Health information technology (HIT) can promote patient safety in many settings. This systematic review found that HIT, such as computerized provider order entry (CPOE) systems, can improve safe prescribing practices in long-term care settings, including improved documentation and clinical processes, and fewer medication errors.

116th Congress 2d session. December 10, 2020.

The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic improvement. The ‘‘Improving Diagnosis in Medicine Act of 2020’’ outlines characteristics of a proposed Federal program to enhance agency cooperation and coordination to improve diagnosis in health care by addressing systemic weaknesses, knowledge gaps, and training issues in the workforce.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Mayo Clin Proc. 2020;95:1842-1844.
This article discusses the threat that the “flexibilization” of science has played during the COVID-19 pandemic, defined as the loosening of methodological standards leading to low-quality studies, and resulting in unreliable data and anecdotal evidence.
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. Adv Simul (Lond). 2020;5:13.
The authors of this article outline ten recommendations for safely reopening simulation facilities for clinical training in the post-lockdown phase of the COVID-19 crisis. The recommendations are based on national guidance and regulations, as well as international public health recommendations. Future reopening activities should focus on safety as well as flexibility principles, taking different contexts and facility characteristics into account.
Amin PB, Bradford CD, Rizos AL, et al. J Pharm Pract. 2020;33:306-313.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Balsom C, Pittman N, King R, et al. Int J Clin Pharm. 2020:Epub Jun 3.
Polypharmacy is one risk factor for medication errors in older adults. This study describes the implementation of a pharmacist-administered deprescribing program in a long-term care facility in Canada. Over a one-year period, residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. The intervention resulted in fewer medications taken by residents the intervention group after 6 months. Most deprescribing recommendations reflected a lack of ongoing indication or a dosage that was too high.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.

Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Dzau VJ, Kirch D, Nasca TJ. N Engl J Med. 2020;383:513-515.
This commentary discusses the ongoing impact of COVID-19 on the physical, emotional, and mental health on the healthcare workforce and outlines five high-priority actions at the organizational- and national level to protect the health and wellbeing of the healthcare workforce during and after the pandemic.  
Vaismoradi M, Vizcaya-Moreno F, Jordan S, et al. Sustainability. 2020;12.
This systematic review identified five articles exploring factors influencing error disclosure and reporting practices by nurses in residential long-term care settings. Nurses were not always willing to disclose errors due to lack of confidence, knowledge and understanding of error disclosure guidance, as well as fear of repercussions, litigation, and loss of trust. Nurse leaders were identified as playing an important role in how incident reports are processed and used for improving safety, and should encourage and support error disclosure.
Ogletree AM, Mangrum R, Harris Y, et al. J Am Med Dir Assoc. 2020;21:604-614.e6.
To support the development of a uniform definition of omissions of care in nursing home settings, the authors conducted a thematic analysis of 34 articles describing existing definitions and found broad agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include adverse events in the definition of omissions of care. The authors reviewed an additional 327 articles reporting adverse events attributable to omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls, and infections.

Rockville, MD: Agency for Healthcare Research and Quality; May 14, 2020.

The unprecedented nature of the COVID-19 pandemic requires unique evaluation strategies to examine system responses to the pandemic and its effects on quality and patient safety. AHRQ will award $5 million in fiscal year 2020 to support novel, high-impact studies that evaluate the responsiveness of health care delivery systems, health care professionals, and the overall U.S. health care system in response to the COVID-19 pandemic. AHRQ expects to fund critical research focused on topics such as the effects on quality, safety, and value of the health system response to COVID-19; the role of primary care practices and professionals during the COVID-19 epidemic; understanding how the response to COVID-19 affected socially vulnerable populations and people with multiple chronic conditions; and the integration of digital health in the response to COVID-19, including innovations and challenges encountered in the expansion of telehealth. The process for submitting applications is now closed.
Song Y, Hoben M, Norton PG, et al. JAMA Netw Open. 2020;3.
The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Int J Equity Health. 2020;19.
To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.
Bates DW, Larizgoitia I, Prasopa-Plaizier N, et al. BMJ. 2009;338:b1775.
This article describes the results from a group of international clinicians, researchers,and policymakers that identified undeveloped research areas in global patient safety.