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1 - 20 of 21

Washington, DC: VA Office of the Inspector General;  February 17, 2022. Report No. 21-01506-76.

Patient suicide is a reoccurring sentinel event that is a challenge for the veteran’s health care community. This report shares the results of 36 unplanned inspections at United States Veterans Affairs facilities. While the inspections found general guidance compliance to be in place, weaknesses in required patient follow-up, staff training and outreach activities were flagged as areas in need of targeted improvement to enhance patient safety.

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.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11.

Incomplete assessment of patient needs can miss opportunities to prevent patient harm. This report analyzes an incident where an intoxicated patient called a dedicated crisis support line yet preventive measures weren’t activated to avert an accidental overdose resulting in patient death. Recommendations for improvement include enhanced training for weekend and holiday staff, standardized safety plan development, and systemized internal review processes.

FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.

US Food and Drug Administration: November 3, 2020.

False-positive results contribute to patient and family discomfort and harm. This announcement shares information for clinicians to improve the reliability of the COVID-19 testing process and highlights government- and staff-level actions to support effective testing.

Geneva, Switzerland: World Health Organization; September 17, 2020.

The intersection of worker well-being and safety with patient harm prevention has become apparent due to COVID-19. This report discusses five areas of importance in motivating lasting change in health care environments to support the safety of the work force. It highlights policy and strategy alignment, occupational considerations, violence reduction, psychological concerns, and physiological harms as essential elements of a robust approach to workforce safety improvement. 

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.

US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.  

Singh H, Bradford A, Goeschel C. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. AHRQ Publication No. 20-0040-1-EF.

This issue brief discusses a sociotechnical approach to understanding safe diagnosis and the range of data sources required for the follow-up and tracking of diagnostic information. The publication recommends a strategy to support health care organizations in identifying and beginning to measure diagnostic error to enable learning. This issue brief is the first in a series on diagnostic safety.
National Quality Forum.
Maternal safety is a growing concern for the patient safety community. This initiative worked with a multidisciplinary panel to develop measures that identify and track factors that contribute to material morbidity and mortality. A set of recommendations drawn from that work provide a framework to generate improvement. The project concluded in 2021. 
AHRQ Health Information Technology Research: 2018 Year in Review. (Prepared by John Snow, Inc. Under Contract No. HHSN316201200068W.) AHRQ Publication No. 19-0082-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2019
A myriad of efforts have been undertaken to enable the safe use of information technologies. This report highlights 141 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records. 

Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.

Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
Preventable patient harm is a global public health concern. This announcement highlights a new partnership initiative co-led by the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement. The committee was formed in response to a call to coordinate a national plan and set of priorities for patient safety improvement efforts across public health and medical care communities.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.