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Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;29:e12421.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.
This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include  improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.
Macías-Colorado ME, Rodríguez-Pérez M, Rojas-Ocaña MJ, et al. Healthcare (Basel). 2021;9:205.
Clear communication between patients, family caregivers, and nurses is crucial to improve patient safety in the home. This qualitative study identified four key concepts around communication of safe family caregiving: communication-related aspects, professional skills of nurse case managers, communication on safety, and the caregiving role. The authors suggest five areas for research to improve patient safety in the home.   

Constellation, Society to Improve Diagnosis in Medicine. 

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.
ten Haken I, Ben Allouch S, van Harten WH. Nurse Educ Today. 2021;100:104813.
Adverse events are common among patients receiving home care, particularly among those requiring complex medication dosing or use of infusion devices. Results from a survey administered to home care nurses in the Netherlands reveal that nurses may not receive practical training or be tested in required skills for the use of advanced medical technologies, such as infusion therapy, parenteral nutrition, or morphine pumps.

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.
Wiley KK, Hilts KE, Ancker JS, et al. JAMIA Open. 2020;3:611-618.
Optimal use of health information exchange approaches such as event notification systems may be influenced by organizational capabilities. This study found that healthcare organizations whose positive perceptions of event alerts fit within existing workflows were more likely to use event notification services to improve care coordination and care quality.
Samad F, Burton SJ, Kwan D, et al. Pharmaceut Med. 2021;35:1-9.
Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning. 

Washington DC; National Quality Forum: October 6, 2020.

With input from a stakeholder committee, the National Quality Forum identified recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Measurement Framework  for measuring and improving diagnostic error and patient safety. The committee developed four ‘use cases’ (missed subtle clinical findings; communication failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error that can result in patient harm. The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing quality improvement activities to engage patients, educate clinicians, leverage technology, and support a culture of safety with the goal of reducing diagnostic errors. 
Cantu J, Tolk J, Fritts S, et al. Appl Ergon. 2020;90:103241.
High reliability organizations have developed methods for achieving safety despite hazardous conditions. In this systematic review, the authors summarize the five “hallmarks” of high reliability organizations (preoccupation with failure; reluctance to simplify interpretations; sensitivity to operations; commitment to resilience; and deference to expertise). The authors also discuss generalizable interventions that can guide systems towards high reliability - process redesign, training, and organization redesign.
Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2020;40:8-15.
The TeamSTEPPS program was developed to support effective communication and teamwork skills in healthcare settings. This evaluation assessed the long-term impact of implementing TeamSTEPPS in ambulatory reproductive health care centers. After two years, survey results indicate that TeamSTEPPS implementation was associated with improved perceptions of teamwork and patient satisfaction and that these tools and strategies were successfully integrated into health center operations.  
Kulju S, Morrish W, King LA, et al. J Patient Saf. 2022;18:e290-e296.
Patient misidentification can lead to serious patient safety risks. Researchers used patient safety reports and root cause analyses (RCA) to characterize patient misidentification events in the Veterans Health Administration (VHA). The incidence of patient misidentification in inpatient and outpatient settings was similar and most commonly attributed to the absence of two unique patient identifiers. The authors identified three strategies to mitigate misidentification based on high-reliability principles: (1) develop policies for patient identification throughout the continuum of care, (2) develop policies to report and monitor patient misidentification measures, and (3) apply quality and process improvement tools to patient identification emphasizing use by front line staff.  

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur.