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Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.
Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;Epub Apr 5.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA OncolEpub 2022 Apr 21. 

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.
Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.
Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
Otachi JK, Robertson H, Okoli CTC. Perspect Psychiatr Care. 2022;Epub Apr 6.
Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.  
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.
Alboksmaty A, Beaney T, Elkin S, et al. The Lancet Digital Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Casalino LP, Li J, Peterson LE, et al. Health Aff (Millwood). 2022;41:549-556.
Physician burnout has been associated with higher rates of self-reported medical errors and increased costs related to physician turnover. This analysis linked survey data from family physicians to Medicare claims to explore any association of burnout with four objective measures of care outcomes (ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs). There was no consistent, statistically significant relationship between burnout and the four measures of care outcomes and further research on this relationship is warranted.
Cucchiaro SÉ, Princen F, Goreux JË, et al. Int J Qual Health Care. 2022;34:mzac014.
Patient satisfaction surveys, unexpected event reports and patient complaints can each be used to improve patient safety. This radiotherapy service combined the three sources to make improvements in safety and quality. Results highlighted areas of strength (e.g., physical healing, kindness) and areas to improve (e.g., scheduling, comfort). Involving the patient in this way could lead to improvements in quality and safety.

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.
Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.
Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).
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.
Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;29:1091-1100.
Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 
Wade C, Malhotra AM, McGuire P, et al. BMJ. 2022;376:e067090.
The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.