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Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.
While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.
AORN J. 2022;115:454-457.
This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
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.

Am J Health Syst Pharm. 2022;79(7): 564-599.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.
Brunelli L, Cristofori V, Battistella C, et al. Int J Integr Care. 2022;22:19.
Accreditation programs are intended to improve patient safety and quality of care. Researchers in Italy aimed to develop and validate an accreditation tool for home care. The tool, validated by 21 experts, is divided into six domains: 1) Organization and governance; 2) Patient safety and risk management; 3) Professionals’ knowledge, skills, and competencies; 4) Information and communication; 5) Care integration, and 6) Improvement and innovation.
Muchiri S, Azadeh-Fard N, Pakdil F. J Patient Saf. 2022;18:237-244.
The Hospital Readmissions Reduction Program (HRRP), implemented by the Centers for Medicare & Medicaid Services (CMS), imposes a financial penalty on hospitals with higher than average readmission rates for certain conditions. Six years of readmission rates for four conditions included in the HRRP (acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia) and two conditions not included (septicemia and mood disorders) were analyzed to assess the impact of the HRRP. The researchers conclude the HRRP reduced readmission rates for the four targeted conditions, but reductions were not consistent across all categories of patients.
Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.
Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool. 
McGinty EE, Bicket MC, Seewald NJ, et al. Ann Intern Med. 2022;175:617-627.
Prior research has found that unsafe opioid prescribing practices are common. This retrospective study explored the association between state opioid prescribing laws and trends in opioid and nonopioid pain treatment among commercially insured adults in the United States. Findings suggest that these laws were not associated with statistically significant changes in prescribing outcomes, but the authors note that some of these estimates were imprecise and may not be generalizable to non-commercially insured populations.
Forrester JD, Maggio PM, Tennakoon L. J Patient Saf. 2022;18:e477-e479.
Healthcare-associated infections (HAIs) result in poorer patient outcomes and increased costs. The 2016 national data set of five common HAIs (surgical site infections, catheter- and line-associated bloodstream infections, catheter-associate urinary tract infections, ventilator-associated pneumonia, and Clostridioides difficile) was analyzed to create an estimated national cost. Clostridioides difficile was the most frequently reported; Clostridioides difficile and surgical site infections accounted for 79% of costs.
Shah RK, Reinhart R, Cronin J. Otolaryngol Clin North Am. 2022;55:105-113.
Experts have advocated the importance of establishing the business case for safety. This article summarizes approaches to establishing the business case for safety through the use of telehealth case-based vignettes as examples. The authors discuss challenges for establishing a business case for safety and future directions.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Shenoy A, Shenoy GN, Shenoy GG. Patient Saf Surg. 2022;16:10.
Defensive medicine refers to clinician behaviors with the intent to avoid malpractice risk due to care omissions. This article provides an overview of defensive medicine and its relationship to the taxonomies of medical errors and the risks that defensive medicine places on patients, hospital administrators, and systems, as well as clinicians.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Steffany M. J Healthc Risk Manag. 2022;41:31-38.
Concerns have been raised regarding the need to assess the competencies of aging physicians. This article discusses how different entities (e.g., health systems, states, and professional medical organizations) are addressing this issue through competency-based assessments, peer review, and credentialing requirements.
Ziedan E, Kaestner R. Eval Rev. 2021;45:359-411.
The Centers of Medicare & Medicaid Service (CMS) Hospital Readmissions and Reduction Program (HRRP) financially penalizes hospitals if patients with certain medical conditions are readmitted. This study analyzed the empirical approaches used in prior research to evaluate the effectiveness of the HRRP. The authors conclude that approaches used in some prior research lacked internal validity and may not indicate causal consequences of the program on readmissions.
DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.
Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.