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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.
Isaksson S, Schwarz A, Rusner M, et al. J Patient Saf. 2022;18:325-330.
Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations. 
Rosen PD, Klenzak S, Baptista S. J Fam Pract. 2022;71:124-132.
Cognitive biases can impede decision-making and lead to poor care. This article summarizes the common types of cognitive errors and biases and highlights how cognitive biases can contribute to diagnostic errors. The authors apply these common types of errors and biases in four case examples and discuss how to mitigate these biases during the diagnostic process. 
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.
Bender JA, Kulju S, Soncrant C. Jt Comm J Qual Patient Saf. 2022;48:326-334.
Healthcare organizations use multiple proactive and reactive methods of investigating and preventing adverse events. This study combined proactive and reactive risk assessments into a Combined Proactive Risk Assessment (CPRA) to identify risks not detected by one method on its own. The four steps of CPRA are illustrated using the example of outpatient blood draws in the Veterans Health Administration.
Falcone ML, Van Stee SK, Tokac U, et al. J Patient Saf. 2022;18:e727-e740.
Adverse event reporting is foundational to improving patient safety, but many events go unreported. This review identified four key priorities in increasing adverse event reporting: understanding and reducing barriers; improving perceptions of adverse event reporting within healthcare hierarchies; improving organizational culture; and improving outcomes measurement.
Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review. 
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;Epub Jun 13.
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.
Kutza J-O, Hübner U, Holmgren AJ, et al. Stud Health Technol Inform. 2022:885-889.
As use of health information technology (IT) applications expands, experts have raised patient safety concerns. Based on a literature review and expert feedback, this article summarizes approaches for assessing digital patient safety maturity in hospitals in order to maximize both health IT implementation and high quality, safe patient care.
Sanchez C, Taylor M, Jones RM. Patient Safety. 2022;4:70-79.
Families and caregivers play an important role in patient safety. This study analyzed incident report data and found that behavior from families and caregivers visiting a patient increased the risk of patient harm in 36% of cases and decreased the risk of harm in the remaining 64% of cases. Certain visitor behaviors (such as moving the patient) increased patient harm, including falls and medication-related events. Other behaviors, such as communicating with healthcare staff, decreased patient harm.
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.
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.
Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.
Bicket MC, Waljee JF, Hilliard P. JAMA Health Forum. 2022;3:e221356.
Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.
Zebrak K, Yount N, Sorra J, et al. Int J Environ Res Public Health. 2022;19:6815.
AHRQ’s Hospital Survey on Patient Safety (SOPS) is used by hundreds of hospitals in the US to assess hospital patient safety culture. This study describes the development and testing of a “workplace safety supplement,” intended to be used in conjunction with the SOPS to assess how organizational culture supports workplace safety. Included survey items measured perceptions around protection from workplace hazards; moving, transferring, or lifting patients; workplace aggression; management and leadership support for workplace safety; and workplace safety reporting.
Nanji K. UpToDate. June 23, 2022.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;Epub May 31.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;Epub Jun 1.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.