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Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37(1):81-83.
Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17(8):e821-e828.
Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.
Upadhyay S, Stephenson AL, Weech-Maldonado R, et al. J Patient Saf. 2021;Epub Sep 28.
This longitudinal study concluded that culturally competent hospitals have better patient safety culture than other hospitals. Based on survey data, results indicate that hospitals with higher levels of engagement in diversity programs had higher perceptions of management support for safety, teamwork across units, and nonpunitive responses.

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

AHRQ’s Hospital Survey on Patient Safety Culture™ (SOPS®) ask health care providers and staff about the extent to which their organizational culture supports patient safety. 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 workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding. You can learn more about the supplemental items and can register for a webcast introducing the Workplace Safety items here: Surveys on Patient Safety Culture™ (SOPS®) | Agency for Healthcare Research and Quality (ahrq.gov)  

Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.

Patient suicide attempts are considered never events. This funding announcement calls for program applications to motivate suicide prevention strategy implementation in the indigenous peoples’ community. The effort anchors on the Zero Suicide initiative to address unique challenges presented by the Indian health system. 
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25(5):17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses to help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Braverman A. Nurs Manage. 2021;52(9):30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30(5):365-374.
The Joint Commission implemented medication management titration standards in 2017, with revisions in 2020. Researchers surveyed critical care nurses about their experiences with medication titration, use of clinical judgment when titrating, nurses’ scope and autonomy, and their moral distress. Of 781 respondents, 80% perceived the titration standards caused delays in patient care and 68% reported suboptimal care, both of which significantly and strongly predicted moral distress.
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.
Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.
The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.
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.

The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented. The COVID-19 pandemic exacerbated burnout risk due to increased emotional exhaustion, stress, and fatigue. In response to effects of pandemic, the University of Minnesota developed the MN Resilience Program. This innovative program leverages the “Battle Buddy” system used in the US Army, and resilience principles to support the psychological and emotional well-being among healthcare workers and to connect healthcare workers to peer support.

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.  

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.

ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.
Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21(1):1038.
Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.
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.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
Fostering a positive safety culture is essential to delivery of safe care. This mixed-methods study of nurses and non-physician health professionals found that staff perceptions of senior leadership, teamwork, and turnover intention were significantly associated with overall patient safety grade.