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Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.
Rocha HM, Farre AGM, Santana Filho VJ. J Nurs Scholarsh. 2021;53:458-467.
Patient boarding in the emergency department (ED) can result in patient harm. This review explored the association between boarding in the ED and quality of care, outcomes, and adverse events. Increased boarding time was associated with poorer quality of care and outcomes.
van der Kooi T, Lepape A, Astagneau P, et al. Euro Surveill. 2021;26.
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality every year. Three mortality review measures were developed to measure the potential contribution of HAIs to patient death. All three measures showed acceptable feasibility, validity, and reproducibility in HAI surveillance.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.

Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17:273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;46:877-886.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18:2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Connolly W, Li B, Conroy RM, et al. J Patient Saf. 2020;17:141-148.
Since the release of To Err is Human, health systems have undertaken a multitude of patient safety initiatives to reduce adverse events. Findings from this systematic review demonstrate minimal reduction in overall risk of adverse event rates that can be attributed to implementation of large-scale patient safety initiatives (e.g. Global Trigger tool in inpatient and geriatric settings). The meta-analysis of included studies estimated one adverse event prevented for every 59 hospital admissions. The authors note a need for more research (particularly large-scale implementation studies) to establish the effectiveness of such initiatives.
Abbas M, Robalo Nunes T, Martischang R, et al. Antimicrob Resist Infect Control. 2021;10:7.
The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.  
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.  
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Crit Care Med. 2021;49:e20-e30.
Common nursing procedures, such as bathing patients in their beds, can result in physiologic changes or accidental displacement of medical devices that may be dangerous to the patient. This study of 254 intensive care patients across Western Europe found that serious adverse events occurred in half of patients during bed bathing.

Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   

Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116:225-233.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
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.