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Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.
Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.
Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.
Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.
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.

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.

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.
Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6:e436.
The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common. 
Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133:698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40:1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.
Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20:134.
A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326:1207.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18:7780.
Informed environmental features, such as the built environment, can improve safety outcomes. The authors propose a theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization, People, and Environment) intended to synthesize design interventions into a systems-based model using the principles of human factors and ergonomics.