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Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;Epub Apr 22.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;Epub Apr 1.
Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.
Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.
Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

 The Collaborative for Accountability and Improvement. May 19, 2022. 2:00 PM (eastern).

The sharing of stories is a key approach for providing information and context to promote change. This webinar will focus on stories drawn from lawsuits, the general patient and family motivation of legal action to minimize the repetition of similar errors, and the ironies involved in the adherence to legal confidentiality that can reduce learning from error.
Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

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.

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

The COVID-19 crisis affected most health care processes, including diagnosis. This report recaps a session examining impacts of the pandemic on diagnostic approaches, inequities, and innovations that may inform future diagnostic improvement efforts.

Rockville, MD; Agency for Healthcare Research and Quality: April 2022.

TeamSTEPPS promotes effective teamwork, collaboration, and communication in health care while focusing on strategies known to improve patient safety. This challenge competition seeks submissions to revise existing TeamSTEPPS videos to improve health literacy, equity, and cultural sensitivity. Written proposals are due June 20, 2022.

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2022 hospital safety grade results are available. A 2019 report from the Armstrong Institute examines avoidable death associated with grading hospitals. 

Human-centered design is a problem-solving approach that focuses on developing and optimizing the efficiency, effectiveness, and usability of products and interactive systems, thereby increasing their safety. This approach prevents patient safety incidents by considering human capabilities, skills, limitations, and needs. Solutions are developed by involving end-user perspectives throughout the process.

Broadly, harm refers to the impairment of the anatomy or physiology of the body and physical, social, or psychological issues arising from the impairment such as disease, disability, or death. In the context of patient safety, the term “adverse event” is used to describe harm to patients that is caused by medical care, as opposed to harm caused by underlying disease or disability. Adverse events can be preventable, ameliorable, or the result of negligence.

Patient and caregiver engagement is centered on providers, patients, and caregivers working together to improve health. A patient’s greater engagement in healthcare contributes to improved health outcomes. Patients want to be engaged in their healthcare decision-making process, and those who are engaged as decision-makers in their own care tend to be healthier and experience better outcomes. Efforts to engage patients and caregivers in safety efforts have focused on three areas: enlisting patients and caregivers in detecting adverse events, empowering patients and caregivers to ensure safe care, and emphasizing patient and caregiver involvement as a means of improving the culture of safety.

Deprescribing is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use. Deprescribing is one intervention that can be applied to reduce the risk for adverse drug events (ADEs) or medication errors associated with polypharmacy.

Debriefing is a brief, planned, and non-threatening conversation that is conducted to review a procedure or event. The goal is to get individuals involved together right after the procedure or event to discuss what went well and to identify areas for improvement. A debrief can help obtain new information after patient safety events such as near misses, adverse events, or medical errors.

Cultural competence includes individual attitudes and behaviors and refers to one’s capacity to appreciate, respect, and interact with members of a different social or cultural group. In healthcare, it includes the ability to provide culturally sensitive care to individuals. To provide person-centered, high quality, and safe care, health care professionals must be prepared to tailor care to prevent adverse events or harm to individual patients from different groups (e.g., race, ethnicity, gender, language, religion, social status). Research has shown that health literacy, English proficiency, lack of trust, and other cultural issues can lead to adverse events, particularly medication errors. Other terms that have been associated with cultural competence include cultural intelligence (knowledge about various cultures and their social context) and cultural humility, both of which assume an approach to care where the provider is sensitive to the cultural context of patients and avoids making assumptions about the patient’s beliefs and environment.

Crisis management is the process by which a team or organization deals with a major event that threatens to harm the organization, its stakeholders, or the general public. Examples of events that may require crisis management include significant adverse events (death of a patient due to a medical error) or a significant environmental event such as a fire. The COVID-19 pandemic is also an example – a public health emergency requiring crisis management early in the event.

Compassion fatigue refers to the physical and mental exhaustion and emotional withdrawal experienced by individuals who care for sick or traumatized people over an extended period. Compassion fatigue can decrease effective teamwork behaviors and increase secondary stress, burnout, depression, or anxiety as well as escalating the use of negative coping behaviors – all of which may have a negative impact on patient safety, as these healthcare workers may commit more errors.

Related term: Burnout

Communication (disclosure) and resolution programs (CRPs) emphasize early admission of adverse events and proactive approaches to resolving patient safety issues. CRPs offer patients empathetic treatment and care after adverse events, even when no harm occurs. These programs focus on transparency, recognizing accountability, acting in a fair, just manner; the use and sustainability of practices to enhance patient safety; and changing disclosure communications to be truly transparent. The CANDOR toolkit, developed by AHRQ, provides organizations with tools necessary to implement a CRP. Whereas the historical approach in response to unexpected harm often followed a "deny-and-defend" strategy (e.g., providing limited information to patients and families, avoiding admission of fault), the CANDOR toolkit uses a person-centered approach and promotes greater transparency and early sharing of errors with patients and families.

Related term: Transparency