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This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

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

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

Thibault R, Abbasoglu O, Ioannou E, et al. Clin Nutr. 2021;40:5684-5709.
Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment. This guidance shares an improvement approach to care environment food provision that considers clinical concerns and patient limitations as steps toward enhancing patient care.
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17:458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2021.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
Institute for Healthcare Improvement.
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next live session is October 7, 2021.
Buhlmann M, Ewens B, Rashidi A. J Clin Nurs. 2020;30:1195-1205.
Adverse events can have significant impacts on the providers involved. This systematic review explored the experiences of critical incidents on nurses and midwives and their perceived support from the healthcare system. The article discusses the emotional, physical, and professional impacts; perceptions of personal, peer and workplace support; and how nurses and midwives move forward and cope with the impact of critical incidents.  
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;128:542-549.
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5. 
 

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education. 
Cicero MX, Adelgais K, Hoyle JD, et al. Prehosp Emerg Care. 2020;25:294-306.
This position statement shares 11 recommendations drawn from a review of the evidence to improve the safety of pediatric dosing in pre-hospital emergent situations. Suggestions for improvement include use of kilograms as the standard unit of weight, pre-calculated weight-based dosing, and dose-derivation strategies to minimize use of calculations in real time.   
Johnson CD, Green BN, Konarski-Hart KK, et al. J Manipulative Physiol Ther. 2020;43:403.e1-403.e21.
An international sample of chiropractic practitioners described actions taken by their practices in response to the COVID-19 pandemic. Practitioners discuss using innovative strategies such as telehealth to continue providing patient-centered care while complying with local regulations.

Galewitz P.  Kaiser Health News. March 25, 2020.

Home care is a common option for older and disabled patients for managing their chronic conditions. This story highlights provider concerns associated with provision of care at home during the COVID-19 pandemic.
Donnelly EA, Bradford P, Davis M, et al. CJEM. 2019;21:762-765.
While fatigue has been linked to safety-related outcomes in many healthcare settings, this link has not been definitively established in paramedicine. This article documents preliminary evidence—based on 717 surveys conducted in ten paramedic services in Ontario, Canada—of a relationship between fatigue and paramedic-reported safety outcomes and safety-compromising behaviors. The authors recommend fatigue mitigation efforts. 
Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Robotics are increasingly used to assist in both complicated and routine activities in health care. Although safety hazards associated with robotic technologies have been explored in surgery, risks related to purely assistive devices is understudied. This review highlights clinician perspectives regarding assistive robots in health care and highlights infection control and reliability issues as concerns associated with their use.
Center for Leadership, Innovation and Research; CLIR.
Emergency medical services harbor unique challenges to safe patient care delivery. This center serves as a patient safety organization for prehospital care providers, provides access to anonymous reporting tool, and hosts educational opportunities that support a culture of safety in the emergency medical services environment.
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Br Dent J. 2018;224:733-740.
This Delphi study aimed to identify expert consensus on never events in dentistry. The resulting list of 23 events includes medication errors, retained objects, and wrong patient and wrong procedure events across diagnostic and treatment activities and is consistent with existing never events in medicine.