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Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2022;176:119-120.
The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
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.

Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.
Zestcott CA, Spece L, McDermott D, et al. J Racial Ethn Health Disparities. 2021;8:230-236.
Implicit bias can contribute to poor decision-making and lead to poor patient outcomes. This qualitative study found that many healthcare providers have negative implicit attitudes about American Indians, such as implicitly stereotyping American Indians as noncompliant patients. The effect of these implicit attitudes and stereotypes was moderated by self-reported cultural competency and implicit bias training.
Bailey ZD, Feldman JM, Bassett MT. N Engl J Med. 2020;384:768-773.
Structural racism affects both population and individual health. This article proposes four key areas in which the medical and public health communities can contribute in order to change policy and social norms: documenting the impact of racism on health; improving the collection and availability of race and ethnicity data; turning the lens to themselves; and, acknowledging that structural racism has been challenged by mass social movements.
Huang C, Koppel R, McGreevey JD, et al. Appl Clin Inform. 2020;11:742-754.
Prior studies have shown that adverse events can increase during the implementation of a new electronic health record (EHR) system. EHR transitions are remarkably expensive, laborious, personnel devouring, and time consuming. This article presents recommendations to facilitate transitions between one EHR system to another and opportunities for problem mitigation to avoid patient safety events.
Turner K, Staggs V, Potter C, et al. BMJ Qual Saf. 2020;29:1000-1007.
Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
Veazie S, Peterson K, Bourne D, et al. J Patient Saf. 2022;18:e320-e328.
This review expands upon previous work evaluating implementation strategies for high-reliability organizations. Review findings indicate that health care system adoption of high-reliability principles is associated with improved outcomes, but the level of evidence is low. Future research should include concurrent control groups to minimize bias and focus on whether certain high-reliability frameworks, metrics, or intervention components lead to greater improvements.  
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.  
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  

Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.

The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.  
Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10:758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.
Bittman J, Nijjar AP, Tam P, et al. J Patient Saf. 2020;16:e169-e173.
This study found that two early warning scores – the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) – can predict patients at risk of deterioration and who will need to be seen by a physician overnight. The authors conclude that use of such early warning scores may be useful for improving handoffs and resource allocation for overnight care.