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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.

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.
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.
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.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
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.  
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:810.
Organizational cultures that encourage psychological safety have been shown to increase safe healthcare. The authors used survey, observational, and interview data to explore psychological safety within four healthcare teams in one hospital. While survey results indicated a high level of psychological safety, observations and interviews identified examples of situations resulting in lower levels of psychological safety, such as absence of learning behavior, low levels of support from other team members, and lack of familiarity among team members.
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.  
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.

ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)

This alert discusses medication errors that have been reported to the Food and Drug Administration involving the preparation, administration, and storage of two formulations of the investigational COVID-19 treatment remdesivir. Recommendations to guide safe practice include use of standard order sets and dosing clarifications.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  
Wood LJ, Wiegmann DA. Int J Qual Health Care. 2020;32:438-444.
This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.    
Cicero MX, Adelgais K, Hoyle JD, et al. Prehosp Emerg Care. 2020;25:294-306.
This position statement shares 11 recommendations drawn from a review of the evidence to improve the safety of pediatric dosing in pre-hospital emergent situations. Suggestions for improvement include use of kilograms as the standard unit of weight, pre-calculated weight-based dosing, and dose-derivation strategies to minimize use of calculations in real time.   
Lyman B, Biddulph ME, Hopper VG, et al. J Nurs Manag. 2020;28:1241-1249.
This study used semi-structured interviews with nurses to explore their experiences with organizational learning. Thematic analyses revealed that organizational learning was more effective when closely aligned with the Organisational Learning in Hospitals model and suggests that health system leadership and nurse managers play a central role in organizational learning.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.