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The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Halvorson EE, Thurtle DP, Easter A, et al. J Patient Saf. 2022;Epub Jul 6.
Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.

Jt Comm J Qual Patient Saf. 2022;365-387.

The memory of John Eisenberg, MD, continues to motivate patient safety improvement. The 2021 honorees for the award presented in Dr Eisenberg’s honor are Hardeep Singh, MD, MPH, Prime Healthcare Services, Ontario, California, Kaiser Permanente Northern California, Oakland, California, and Mark R. Chassin, MD, FACP, MPP, MPH.

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Institute for Healthcare Improvement. September 14--November 22, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

Collaboration for Better Care. September 13, 2022, Royal Society of Medicine, London, England.

Achieving sustained patient safety improvement is an ongoing goal. This conference will feature a keynote address on the National Health Services’ Patient Safety Strategy and sessions on a variety of patient safety topics including infection prevention and control, remote patient monitoring for patient safety, leadership role in speaking up culture, and learning from patient safety incidents and investigations.
Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.
Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.
Joint Commission, National Quality Forum.
The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application procedure. The deadline for submitting an application for the 2022 award cycle is September 14, 2022.

Infect Control Hosp Epidemiol. 2022.

 

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022 to summarize preemptive actions and implementation strategies for prevention of HAIs.

National Patient Safety Board. 2021-2022.

Patient safety expertise builds on a wide range of subjects to inform progress. This webinar series features discussions on topics spanning concerns that impact effective care delivery such as peer evaluation, systemic failures, human factors, and big data. A June 2022 discussion guide accompanies the series to support conversation and reflection.

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Liberman AL, Cheng NT, Friedman BW, et al. Diagnosis (Berl). 2022;9:225-235.
Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.

Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application deadline is July 31, 2022.
Findling MG, Zephyrin L, Bleich SN, et al. Healthc (Amst). 2022;10:100630.
Health inequities among people of color are the result of multiple systemic and clinician factors. This study shows Black and Hispanic/Latino patients who experience racism in healthcare, report worse views on the quality of their care and lower trust in their clinicians. These findings suggest that eliminating racism at the organization and clinician level may improve quality of care for patients of color.
Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. BMC Health Serv Res. 2022;22:722.
Medication reconciliation can reduce medication errors, but implementation practices can vary across institutions. In this study, researchers compared data for patients from six hospitals and different clinical departments and found that hospitals differed in the number and type of medication reconciliation interventions performed. Qualitative analysis suggests that patient mix, types of healthcare professionals involved, and when and where the medication reconciliation interviews took place, influence the number of interventions performed.
Institute for Safe Medication Practices.
The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety.  The deadline for submitting nominations for the 2022 award cycle is September 9.