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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.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259

Nursing homes face significant patient safety challenges, and these challenges became more apparent during the COVID-19 pandemic. This report identifies key issues in the delivery of care for nursing home residents and provides recommendations to strengthen the quality and safety of care delivery, such as improved working conditions, enhanced minimum staffing standards, improving quality measurement, and strengthening emergency preparedness.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36:3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Rodrigo Rincón I, Irigoyen Aristorena I, Tirapu León B, et al. BMC Health Serv Res. 2021;21:31.
Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. BMJ Open. 2020;10:e035238.
Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.

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.
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns. 
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.   

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.   
Chauhan A, Walton M, Manias E, et al. Int J Equity Health. 2020;19:118.
In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.
Sanko JS, Mckay M. Simul Healthc. 2020;15:167-171.
This study found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.

Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Maatman TC, Prigmore H, Williams JS, et al. BMJ Qual Saf. 2019;28:934-938.
This educational intervention used a comic book format to convey patient safety concepts to internal medicine residents. Awareness and confidence in patient safety topics including medication safety and fall prevention improved on the post-test compared to the pre-test, suggesting this modality has promise as a patient safety education tool.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.