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Díez R, Cadenas R, Susperregui J, et al. Int J Environ Res Public Health. 2022;19:4313.
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.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Fischer SH, Shih RA, McMullen TL, et al. J Am Geriatr Soc. 2022;70:1047-1056.
Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process. 

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259

Nursing homes face significant patient safety challenges, and these challenges became more apparent during the COVID-19 pandemic. This report identifies key issues in the delivery of care for nursing home residents and provides recommendations to strengthen the quality and safety of care delivery, such as improved working conditions, enhanced minimum staffing standards, improving quality measurement, and strengthening emergency preparedness.

Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.

Improving diagnosis and reducing diagnostic errors are patient safety priorities. This announcement supports the development of Diagnostic Centers of Excellence focused on improving frontline diagnostician support and improving diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference standards). Applications are due by June 9, 2022.
Paulik O, Hallen J, Lapkin S, et al. J Patient Saf. 2022;18:e613-e619.
Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).
Willis E, Brady C. Nurs Open. 2022;9:862-871.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
Medication errors are common among older adults discharged to long-term care facilities. Researchers reviewed medication discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted or re-admitted residents had at least one medication discrepancy discovered at nursing home intake. Residents who were prescribed 14 or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest risk for discrepancies. Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance of medication reconciliation for residents with respiratory conditions or pain.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.

Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.
Irons MW, Auta A, Portlock JC, et al. Home Health Care Serv Q. 2022;41:91-123.
Care home residents experience high rates of medication errors. Thirty-two articles about medication errors in UK care homes were included in this review. Articles covered causes, rates, recommendations, and/or evaluation of interventions on error rates. The authors recommend development of more robust strategies for evaluating medication errors in care homes.
Stephens S. J Healthc Risk Manag. 2022;41:17-26.
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. 

Occupational Safety and Health AdministrationMarch 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258.

Human factors concepts are central to improvement in high-risk industries and efforts are emerging to enfold them into health care organizations to improve safety. This special issue explores themes that underscore successful application of human factors practices into healthcare: culture change toward high reliability, team improvement, technology integration, and measures development.

Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.

Health information technologies (HIT) and advanced learning systems, if poorly designed, used, maintained, integrated, or accessed, harbor the potential for failure across the systems they support. This legal discussion argues for federal standards to establish levels of accountability for physicians who use HIT systems and assign liability, should use result in patient harm.

Katz MJ, Tamma PD, Cosgrove SE, et al. JAMA Netw Open. 2022;5(2):e220181.

Overuse of antibiotics has been common in nursing homes; therefore, antibiotic stewardship programs (ASPs) have been emphasized by experts. To assist facilities, the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use developed programs and a toolkit to improve the appropriate use of antibiotics. This quality improvement program found that a focused educational initiative to establish ASPs in nursing homes was associated with reduction in antibiotic use in those facilities with high levels of engagement.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.

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.
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated