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Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82:1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40:1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;28:2346-2353.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33:mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.
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.
Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;43:324-339.
The goal of the patient centered medical home (PCMH)  model is to reorganize primary care to provide team-based, coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety concerns (e.g., medication safety, diagnostic error, treatment delays, communication or coordination errors) in the context of the PCMH model and explore variability in the implementation of patient safety practices.
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.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4:e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
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.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Netw Open. 2021;4:e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
Myers LC, Blumenthal KG, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47:54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.  

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.
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
Griffith PB, Doherty C, Smeltzer SC, et al. J Am Assoc Nurse Pract. 2020;33:862-871.
Cognitive debiasing can help reduce cognitive bias and improve clinical decision-making. This scoping review characterized cognitive debiasing strategies used by student health care providers (primarily medical students and residents) to reduce cognitive error. Structured reflection and education initiatives demonstrated the greatest improvements in diagnostic accuracy.
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.