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Trenton, NJ: New Jersey Department of Health and Senior Services.
Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.
Okemos, MI: Michigan Health & Hospital Association.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This most current year's achievements include submission of 134 root cause analysis to the state patient safety organization reporting system. Areas of focus for improvement work included obstetrical safety, workplace safety, and COVID-19 and infection control.
Atlanta, GA: Centers for Disease Control and Prevention; October 2021.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2020 revealed increases in central line–associated bloodstream infections and other infections while a decrease in surgical site infections. The current report also discusses the impact of COVID-19 on reporting and data submission efforts.
Schneider EC, Shah S, Doty M, et al. New York, NY: The Commonwealth Fund; August 2021.
A cross-national survey of consumers and physicians reveals that, despite its costliness, the United States health care system continues to rank lower than other countries in quality of care performance.

Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422.

Decision making is vulnerable to human influences such as fatigue, interruption and bias. This book provides case examples of how 60 cognitive biases can degrade clinical reasoning in the emergency department and shares tactics that minimize their potential impact on thinking.

National Academies of Sciences, Engineering, and Medicine. Washington DC:  National Academies Press; 2021. ISBN: 9780309685061. 

Health care system safety and effectiveness requires an engaged and empowered nursing workforce. This report builds on the foundation of nursing as a core care contributor. It shares a framework positioning nurses to improve equity, reduce disparities and support family-centered care in the future through education, healthy work environments and enhanced professional autonomy.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743. 

Diagnostic error reduction methods are evolving to enhance efforts supporting diagnostic improvements. This publication uses clinical cases to examine cognitive elements that contribute to problematic decision making. The model illustrates how bias and other reasoning flaws are more likely to result in diagnostic errors than a lack of knowledge would. 

Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact.   

HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020. Report number OEI-02-19-00130.

Misuse of prescription opiates in the US continues to be a patient safety concern.  This data brief summarizes characteristics of the Medicare Part D population that routinely use opiates. It provides insights into the prevalence of patients diagnosed with opioid use disorders and others at risk for abuse that receive prescriptions for opioids.  A recommendation shared to address the situation is to assure patients diagnosed with the disorder get the medication-assisted treatment they need.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey. Washington DC; 2020.

Surgical volume standards are a metric used to assess the needed experience in performing distinct types of procedures. This report analyzed data from over 2,100 hospitals and found approximately half to be deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries
Colleges A of MR. London, UK: Academy of Medical Royal Colleges; 2020.
A foundational understanding of safety is core to building reliable care processes and teams. This report outlines a curriculum that was developed in response to a national improvement strategy for National Health Service staff. The training program highlights the themes of the systems approach, risk competencies, human factors and safety culture as linking content domains together to develop safe practitioners.
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509.
Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.