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Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;Epub Jan 5.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is February 11, 2022.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Gampetro PJ, Segvich JP, Hughes AM, et al. J Pediatr Nurs. 2021;63:20-27.
Communicating and reporting patient safety incidents relies on a robust safety culture wherein health care providers feel supported, not blamed, for errors. Using pediatric registered nurses’ responses from the 2016 and 2018 Hospital Survey on Patient Culture, researchers explored (1) associations between the communication of RNs within their teams and the frequency that they reported safety events; (2) associations between RNs’ communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs’ communication had improved from 2016 to 2018.

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17(8):531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4(12):e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.
Institute for Healthcare Improvement and British Medical Journal. March 30 - April 1 2022, Gothenburg, Sweden.
This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Creating tomorrow today: how does quality improvement shape the “new normal” " will cover topics such as healthcare inequality, safety culture, and patient partnerships. 
Schefft M, Noda A, Godbout E. Curr Treat Options Pediatr. 2021;7(3):138-151.
Overuse of medical care represents a significant patient safety challenge. This review discusses the impacts of healthcare overuse and unnecessary care on patient safety, including contributions to avoidable adverse events, increasing risks for healthcare-acquired infections, and adverse psychological outcomes.

Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371. 

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.
Attia E, Fuentes A, Vassallo M, et al. Am J Health Syst Pharm. 2021;Epub Nov 2.
Anti-coagulants are classified as high-risk medications due to their potential to cause serious patient harm if not administered correctly. This hospital created a multidisciplinary anticoagulant safety taskforce to reduce errors and improve patient safety. The article describes the implementation process, including the use of the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy tool.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2:00-3:00 PM (eastern).

An organization’s understanding of its culture is foundational to patient safety. This webinar will introduce the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session will cover the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4(4):ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.

ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.
Ang D, Nieto K, Sutherland M, et al. Am Surg. 2021;Epub Nov 12.
Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality.  Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).
Phillips R  A, Schwartz RL, Sostman HD, et al. NEJM Catalyst. 2021;2(12).
This article summarizes the principles of high reliability organizations (HROs) and how one healthcare organization sought to become an HRO by emphasizing a culture of safety and the learning healthcare system. The authors discuss how the principles of high-reliability were successfully leveraged during the COVID-19 pandemic.
McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.