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Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Schouten B, Merten H, Spreeuwenberg PMM, et al. J Patient Saf. 2020;17:166-173.
Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.

Alemi F ed. Special Section: Event Analysis and Risk Management. Qual Manag Health Care. 2020;29(4):232-278.

Adverse event analysis is core for organizational learning from poor performance. This special section discusses how examination tools such as failure mode and effect analysis and root cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement.

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  
Sim MA, Ti LK, Mujumdar S, et al. J Patient Saf. 2022;18:e189-e195.
This article describes the implementation of a hospital-wide patient safety strategy aimed at reducing hospital-wide adverse events at a single large hospital in Singapore. The strategy included establishing interdisciplinary patient safety teams to identify areas of preventable harm, determine root causes, improve departmental accountability, and leveraging simulation training. Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining interventions, or death.
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.
Lee SE, Vincent C, Dahinten S, et al. J Nurs Scholarsh. 2018;50:432-440.
This secondary analysis combined survey data from individual nurses with hospital safety culture data and found that both individual characteristics such as education level and hospital characteristics such as safety culture were associated with risks of medication administration errors and falls. The authors conclude that improving safety culture should be a high priority.
Gartshore E, Waring J, Timmons S. BMC Health Serv Res. 2017;17:752.
Nursing homes and other long-term care facilities struggle with establishing a safety culture. This scoping review sought to assess the status of safety culture and improvement in residential care. Researchers found that the number and rigor of studies available were lacking and none of the studies included insights from the patients and families using the facilities.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.