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Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.

Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.

Andreou A. Scientific AmericanMay 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

Sausser L. Kaiser Health News. May 24, 2022.

Lack of education contributes to misunderstandings and unhelpful preconceptions. This article discusses biases affecting the care of patients who are overweight. It introduces an educational effort to raise awareness of potential diagnostic and treatment actions affected by clinician bias to decrease safety for this patient population.

ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

DePeau-Wilson M. MedPage Today. May 13, 2022. 

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.

Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5. 

Practice changes take time to be fully incorporated into daily work. This article shares survey results examining how hospitals implement best practices to enhance the safe use of oxytocin, improve vaccine administration through bar coding, and deploy multifaceted strategies to reduce high-alert medication errors. Gaps in uptake were reviewed and recommendations for improvement shared.

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

The APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Laber-Warren E. MedPage Today. April 5, 2022.

Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news article highlights situations where resident autonomy should be disclosed to patients (such as instances of overlapping surgeries) and the value of transparency about the role of surgical team members.

Loller T. Associated PressMarch 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.