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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.
Falk A-C, Nymark C, Göransson KE, et al. Intensive Crit Care Nurs. 2022:103276.
Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.
Lefosse G, Rasero L, Bellandi T, et al. J Patient Saf Risk Manag. 2022;27:66-75.
Reducing healthcare-acquired infections is an ongoing patient safety goal. In this study, researchers used structured observations to explore factors contributing to healthcare-related infections in nursing homes in one region of Italy. Findings highlight the need to improve the physical care environment (e.g., room ventilation), handwashing compliance, and appropriate use of antibiotics.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;Epub Apr 5.
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.

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.
Wieringa S, Neves AL, Rushforth A, et al. BMJ Qual Saf. 2022;Epub Mar 8.
The COVID-19 pandemic dramatically increased the use of telehealth, including remote primary care triage and assessment. This qualitative study explored patients’ and clinicians’ experiences managing suspected COVID-19 during remote triage and assessment. Findings highlight the need to strengthen organizational resilience, develop and implement triage decision support tools, and address vulnerable and unsupported groups (e.g., the elderly, vulnerable and homebound patients).

Occupational Safety and Health AdministrationMarch 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.
Mullur J, Chen Y-C, Wickner PG, et al. J Patient Saf. 2022;18:e431-e438.
COVID-19 restrictions and patient safety concerns have greatly expanded the use of telehealth and virtual visits. Through patient satisfaction surveys and patient complaints, this US hospital evaluated the quality and safety of virtual visits in March and April of 2020. Five patient complaints were submitted during this timeframe and overall patient satisfaction remained high. Safety and quality risks were identified (e.g., diagnostic error) and best practices were established.

Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Labrague LJ, Santos JAA, Fronda DC. J Nurs Manag. 2022;30:62-70.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.  
Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.
The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.

Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.
Messing EG, Abraham RS, Quinn NJ, et al. Am J Nurs. 2022;122.
When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.
Wells HJ, Raithatha M, Elhag S, et al. BMJ Open Qual. 2022;11:e001551.
Use of personal protective equipment is necessary to reduce the spread of infectious diseases, such as COVID-19, in healthcare settings. The alertness levels of ICU staff who regularly wore full personal protective equipment (FPPE), i.e., respirator mask, body covering suit, visor, gloves, and hat, were tested when not wearing FPPE and after two hours wearing FPPE. Results show health care worker alertness can be negatively impacted by wearing FPPE for as little as two hours.
Willis JS, Tyler C, Schiff GD, et al. Am J Med. 2021;134:1101-1103.
Telemedicine has become a more accepted care mode due to the COVID pandemic and general rural care access issues. This commentary suggests a 5-part framework for examining patient, physician, technological, clinical and health system influences on care management decisions that affect the safety of telediagnosis in primary care.

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Preston-Suni K, Celedon MA, Cordasco KM. Jt Comm J Qual Patient Saf. 2021;47:673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic