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London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.

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.
Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Int J Environ Res Public Health. 2021;18:5335.
The beginning of the COVID-19 pandemic immediately changed how patients sought healthcare. This study analyzed the change frequency of diagnoses made in 2019 compared to 2020 in one region of Spain. On average, the number of diagnoses declined 31% from 2019 to 2020, with cancer diagnoses declining by nearly 50%. As COVID-19 cases continue to decrease in many areas in 2021, the authors recommend local, regional, and national public health leaders prioritize plans to target under-diagnosed conditions.
Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021).
The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units. Other factors associated with violence in health care settings include stressful conditions, understaffing, and lack of organizational policies for recognizing and deescalating hostile behaviors. The alert suggests numerous strategies health care organizations can take to mitigate workplace violence, such as establishing systems across the organization that enable reporting of workplace violence and developing quality improvement initiatives to reduce such incidents. A past PSNet perspective explored how a team at Beth Israel Deaconess Medical Center developed a process to improve workplace safety.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4:e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.  

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Chicago, IL: Accreditation Council for Graduate Medical Education; March 2021.

Clinician well-being is a cornerstone to safe care delivery. This report summarizes a leadership discussion examining systemic factors that detract from healthcare workforce wellness, current strategies to address those factors, and barriers to improvement.
Park S-H, Stockbridge EL, Miller TL, et al. PLoS One. 2020;15:e0235754.
This study merged inpatient discharge data with annual survey data from the American Hospital Association and found that private patient rooms were significantly associated with fewer hospital-acquired MRSA infections; however the effect of private rooms is disproportionate across hospitals. Hospitals with fewer private rooms stand to see the greatest decrease in MRSA infections from adding additional private rooms. These findings can assist hospital administrators making decisions about facility design and renovation.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.
Am Geriatr Soc. 2020;68:908-911.
This policy brief presents the American Geriatric Society’s recommendations for caring for patients with COVID-19 in nursing homes and long-term care facilities. Recommendations focus on the production and distribution of personal protective equipment (PPE), patient transfer between hospitals and nursing homes, public health planning, workforce issues, and payment and tax relief for nursing homes. The brief reflects federal guidance as of April 4, 2020.

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

Clark C. MedPage Today. February 10, 2020. 

It is an institutional responsibility to monitor physicians exhibiting performance issues that put patients into unsafe situations. This news story highlights one hospital system’s lack of action and policy adherence that failed to appropriately manage a physician with known substance abuse issues. 
Allhoff F. Kennedy Inst Ethics J. 2019;29:187-203.
Medical error is an important problem but there has been little examination of associated conceptual and normative aspects. This article explores the association between medical errors and adverse events, challenges current ideas about what comprises a medical error, and considers the concept of moral luck in the context of medical errors. The author introduces a noteworthy argument related to the differences in how we think of undertesting and overtesting and, by extension, underdiagnosis and overdiagnosis.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Pallok K, De Maio F, Ansell DA. N Engl J Med. 2019;380:1489-1493.
This editorial discusses how structural racism contributes to health inequities between blacks and whites in the United States, with an emphasis on cancer care. The authors propose three strategies for addressing structural racism in healthcare: (1) clinicians can make the invisible visible by examining disparities in their practices and exploring disparities in patient-level quality measures; (2) health care organizations can engage the community in an effort to change the accepted explanatory narrative, from one about biology or behavior to a story of a pathological social system that can be improved, and; (3) institutions can make systemic changes to eliminate structural racism by engaging in quality improvement efforts, educating healthcare workers, updating technical skills, and using patient navigators to connect patients to necessary services.