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Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

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.
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..

Oakbrook Terrace, IL: Joint Commission: April 19, 2022.

The Eisenberg Award recognizes individual and organizational accomplishment toward patient safety and quality improvement. The 2021 honorees are Hardeep Singh, MD, MPH, Prime Healthcare Services, Ontario, California, Kaiser Permanente Northern California, Oakland, California, and Mark R. Chassin, MD, FACP, MPP, MPH. The awards will be presented virtually during the National Quality Forum's annual meeting in July.
Anesthesia Patient Safety Foundation.
This grant program supports research that seeks to improve anesthesia safety and the development of researchers in the specialty. The application process for submitting a grant application for the 2022 funding cycle of the primary solicitation for investigator initiated research (IIR) grants is now closed. Other opportunities for funding become available on a periodic basis.

Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.
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.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Moureaud C, Hertig JB, Dong Y, et al. Health Policy (New York). 2021;125:1421-1429.
Based on survey responses from 1,002 participants, this study evaluated how social media users assess, interact and engage with information related to the illegal sales of prescription medicines. Findings suggest that individuals generally perceive online pharmacies and social media platforms to be safe and respondents are confident in their ability to acquire legitimate medicines. The authors note that this false confidence has the potential to lead to patient harm given the prevalence of counterfeit and substandard medication available on these platforms.
Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326:411-419.
Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering. 
Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.
Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through May 27, 2025.
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 27, 2023.
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.

National Academies of Sciences, Engineering, and Medicine. Washington DC:  National Academies Press; 2021. ISBN: 9780309685061. 

Health care system safety and effectiveness requires an engaged and empowered nursing workforce. This report builds on the foundation of nursing as a core care contributor. It shares a framework positioning nurses to improve equity, reduce disparities and support family-centered care in the future through education, healthy work environments and enhanced professional autonomy.
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.  

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.