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Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.

Effective incident reporting systems play an essential role in identifying and mitigating patient safety threats. This article discusses the need for a standardized approach to incident report analysis and how qualitative content analysis can support incident analysis and help identify risk mitigation strategies, performance improvement initiatives, and educational opportunities for healthcare workers. 

The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.

Patient isolation for infection prevention and control may result in unintended consequences. This systematic review examined adverse physical and psychosocial events associated with patient isolation. A meta-analysis of seven observational studies showed no adverse events related to clinical care or patient experience with isolation.

Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.

A culture of safety in nursing homes has been linked to improved resident care. The authors describe how the alignment of regulatory oversight and surveys could integrate with just culture to improve resident safety.  

Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

This article presents a COVID-19 infection prevention and control plan for nursing homes, emphasizing protections for healthcare professionals, prevention of infection spread among residents, management of COVID-19 cases and limiting access to visitors.

This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.

Based on data from the CMS COVID-19 Nursing Home Database, this study found that more than 20% of nursing homes report a severe shortage of personal protective equipment (PPE) and shortage of staff; rates for staffing and PPE did not improve from May to July of 2020. Nursing homes with COVID-19 cases among residents and staff, and those with lower quality scores, were more likely to report shortages.

The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.

These authors discuss the effect of the COVID-19 pandemic on burnout and moral distress among nurses and outline several recommendations to support nurses, promote resilience, and maintain patient outcomes during and after the pandemic.

The authors of this commentary propose a communication checklist for healthcare workers regarding potential health care-associated exposure to COVID-19. Key elements include identifying individuals responsible for communicating with and supporting potentially exposed health care workers; curtailing spread through timely disclosure and transparency; establishing clear guidance for health care workers and management; and providing essential resources for healthcare worker dealing with an exposure, such as peer support or remote work.