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This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;15:28-41.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.

Health information technologies (HIT) and advanced learning systems, if poorly designed, used, maintained, integrated, or accessed, harbor the potential for failure across the systems they support. This legal discussion argues for federal standards to establish levels of accountability for physicians who use HIT systems and assign liability, should use result in patient harm.
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Hartstein B, Munante M, Toor PA. NEJM Catalyst. 2022;3:e1-e20.
High-reliability organizations (HROs) are able to “manage the unexpected” while operating under challenging conditions. This article describes the U.S. Medical Department’s systemwide rollout of the Top Six HRO communication practices. The authors summarize how the Top Six campaign was developed and discuss the implementation of six systemwide initiatives to increase reliability – (1) daily safety briefings; (2) safety leadership rounds; (3) unit-based huddles; (4) Situation Background Assessment Recommendation (SBAR) for communication; (5) briefs and debriefs for surgical cases; and (6) Universal Protocol before every procedure.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;18:3534-3541.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.
Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.
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.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.
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.