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Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.
Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99(10):693-707F.
Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.

Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.
Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18(10):e1003816.
Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.
Svensson J. J Patient Saf. 2021;Epub Aug 5.
Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance – (1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerized methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence, and falls.
Skoogh A, Hall-Lord ML, Bååth C, et al. BMC Health Serv Res. 2021;21(1):1093.
Improving maternal safety is a priority patient safety issue. Using the Global Trigger Tool, researchers found that nearly three-quarters of adverse events in one labor ward in a Swedish hospital were preventable. Common events included lacerations and anesthesia-related events and often resulted in a prolonged hospital stay.
Alanazi FK, Sim J, Lapkin S. Nurs Open. 2022;9(1):30-43.
Nurse attitudes towards patient safety culture have shown to impact missed nursing care, iatrogenic harm, and other adverse events. This review synthesizes research on nurses’ safety attitudes and subsequent impact on patient outcomes. While most data on adverse events was self-reported, nurses indicated an improved safety culture resulted in fewer reported adverse events. Nurse managers can play an important role in improving patient safety culture and outcomes in their hospital units.
Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38(12):1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.
Hussein M, Pavlova M, Ghalwash M, et al. BMC Health Serv Res. 2021;21(1):1057.
Accreditation programs, such as Magnet Hospital Program and The Joint Commission, are intended to improve hospital patient safety and quality. This review of 76 studies suggests accreditation has a positive impact on safety culture, efficiency and length of stay. Effects on mortality and healthcare-associated infection rates were mixed.
Klimmeck S, Sexton BJ, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47(12):783-792.
Safety WalkRounds involve health care leadership or managers visiting frontline staff and engaging in discussions about safety concerns. One university hospital in Switzerland combined WalkRounds with structured in-person observations which helped identify safe care practices and deficits in patient safety. However, there were no significant changes in safety and teamwork climate nine-months after implementation.  
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6(5):e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18(15):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.

Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

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.