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Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.
Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.

Loller T. Associated PressMarch 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
Upadhyay S, Stephenson AL, Weech-Maldonado R, et al. J Patient Saf. 2022;18:e680-e686.
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.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.
Hussein M, Pavlova M, Ghalwash M, et al. BMC Health Serv Res. 2021;21:1057.
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.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2022;37:188-194.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Nævestad T-O, Storesund Hesjevoll I, Elvik R. Accid Anal Prev. 2021;159:106228.
Healthcare organizations are increasingly investing in promoting culture of safety to improve patient safety outcomes but few, if any, regulations exist influencing safety culture in healthcare. In a review of how regulators influence safety culture in several high-reliability fields, the authors identified six relationships between regulators and safety behavior and accidents. If healthcare regulators are to successfully influence safety culture in healthcare, attention must be paid to each relationship.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3:221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
O'Neill N. Nursing (Brux). 2021;51:54-56.
Individuals who express concerns can identify latent conditions that degrade safety in health care. This article examines this behavior in the context of the COVID pandemic and staff safety. The author highlights instances of peer and organizational retaliation against whistleblowers.
Biquet J-M, Schopper D, Sprumont D, et al. J Patient Saf. 2021;17:e1738-e1743.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.  

Alemi F ed. Special Section: Event Analysis and Risk Management. Qual Manag Health Care. 2020;29(4):232-278.

Adverse event analysis is core for organizational learning from poor performance. This special section discusses how examination tools such as failure mode and effect analysis and root cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement.

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.

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.