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Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2022;Epub Jul 6.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
Quesenberry M. Patient Safety. 2022;4:6-9.
Medical devices intended to improve patient safety can unintentionally lead to patient harm. This patient safety alert draws attention to the risk of injury when hospital wheelchairs are used by staff, patients, or visitors who may not have training in safe use. Understanding the proper use of the wheelchair, particularly folding wheelchairs, is crucial to ensuring safety.
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18:444-448.
Effective patient safety improvement efforts address safety threats at the individual, interpersonal, and organizational levels. This study characterizes safety measures described in incident reports from German outpatient care settings. Of the 243 preventative measures identified across 160 reports, 83% of preventative measures were classified by the research team as “weak,” meaning that they focus on influencing human behavior rather than on treating underlying problems (e.g., alerts, trainings, double checks).
Taylor DJ, Goodwin D. J Med Ethics. 2022;Epub Jul 8.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.
Koch A, Kozhumam A. Health Promot Pract. 2022;23:555-559.
Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.
van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18:617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2022;Epub Aug 10.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Violato E. Adv Health Sci Educ Theory Pract. 2022;Epub Jun 6.
Speaking up behaviors are a key indicator of psychological safety and a culture of safety. This article synthesizes the evidence on various aspects of speaking up behavior, including effective interventions to encourage speaking up, factors that positively influence speaking up, and the role of simulation training to develop speaking up skills.  

Garcia AD, Lopez X. AMA J Ethics. 2022;24(8):e753-e761. 

Implicit bias, discrimination, and stigmatization impact patient care. This article discusses unique care experience considerations for transgender people of color. It recommends actions individual clinicians can take to reduce inequalities, improve communications, and enhance patient-centeredness.
Olans RD, Olans RN, Marfatia R, et al. Jt Comm J Qual Patient Saf. 2022;48:552-558.
Inadequate or incorrect documentation of patient allergies can lead to patient harm. This commentary discusses factors contributing to penicillin allergy documentation errors within electronic heath record systems (EHRs) and how EHR alerts can be used to improve safety around penicillin allergies.
Alper E, O'Malley TA, Greenwald J. UpToDate. August 18, 2022.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.
Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.
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.
Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
Bamberger E, Bamberger P. BMJ Qual Saf. 2022;Epub Apr 15.
Disruptive behaviors are discouragingly present in health care. This commentary discusses evidence examining the impact of unprofessional behaviors on safety and clinical care. The authors suggest areas of exploration needed to design reduction efforts such as teamwork, the Safety I mindset and targeting of the root influences of impropriety.
Hunter J, Porter M, Cody P, et al. Int Emerg Nurs. 2022;63:101174.
Many aspects of crew resource management in aviation, such as the sterile cockpit, are used in healthcare to increase situational awareness (SA) and decrease human error. The situational awareness of paramedics in one US city was measured before and after receiving a targeted educational program on situational awareness. There was a statistically significant increase in SA following the intervention, although additional research is needed with larger cohorts.
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.