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Whatley C, Schlogl J, Whalen BL, et al. Jt Comm J Qual Patient Saf. 2022;48:521-528.
Newborn falls or drops are receiving increasing attention as a patient safety issue. This article discusses a quality improvement initiative launched at one hospital aimed to decrease newborn falls through new parent education materials, a nursing risk assessment tool, and standardized reporting system. Three years after implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries over the three-year period.

Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-4-EF.

Nurses are underutilized as members of the diagnostic team. This publication examines the role of nursing educators and leaders to enhance the participation of nurses in diagnostic processes. It shares strategies for improving diagnosis through nurse engagement in the process. This issue brief is part of a series on diagnostic safety.

NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC, American Association of Medical Colleges or virtual; October 3, 2022, 10:00 AM – 12:00 PM (eastern).

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This webinar will discuss the culmination of a six-year effort to design a national multidisciplinary guidance to address system issues that affect the wellbeing of clinicians.

Thomas Jefferson University, College of Population Health. September 30 - November 18, 2022.

Leaders have a distinct role in creating a culture that supports a high reliability organization(HRO). This virtual series will train senior acute care, long-term care, or skilled nursing facility staff to apply HRO concepts that support safe healthcare environments.
AHA Training. November 9-10, 2022. Hilton Garden Inn, Houston, TX.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

AHA Team Training. October 6 – November 17, 2022.

Despite the recognition that teamwork is essential to safe care, its implementation into established processes can be a challenge. Building on the established TeamSTEPPS® principles, this virtual workshop series focuses on leadership, change management and process integration to enrich organizational efforts to embed effective teamwork into care.
Harris CK, Chen Y, Yarsky B, et al. Acad Pathol. 2022;9:100049.
Physicians, including resident physicians, report safety events at lower rates than nurses and other staff. This study analyzed adverse event and near miss reporting by residents in one American hospital. Although pathology residents accounted for more than 5% of residents in the hospital, they only accounted for 0.5% of all reports.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Hospital Quality Institute. Long Beach, CA (October 3-4, 2022) and Napa, CA (November 6-7).

Zero harm is a stated goal across health care. This in-person conference will be held in two locations to bring improvement experience from the front line to regional audiences. Each event will feature a track examining health equity and implicit bias as factors in safe care provision.
Hoffman S. J Med Regulation. 2022;108:19-28.
Patient safety advocates have called for cognitive testing of aging clinicians and some health systems have attempted instituting such policies as part of their recredentialing program. This commentary calls for state medical boards to adopt cognitive testing as part of the recredentialling process within the confines of legal boundaries.

Washington DC; National Quality Forum and Anticoagulation Forum; 2022.

Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can result in considerable harm. This document advocates that a stewardship approach be applied to anticoagulant therapy to reduce the risk of adverse events and discusses steps to implement and sustain a program to guide the safe, effective use of anticoagulants.
Koch A, Kozhumam A. Health Promot Pract. 2022;23:555-559.
Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.
van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18:617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.

Oregon Patient Safety Commission. October 18-19, 2022.

Learning from regional experience can take advantage of commonalities shared across disparate topics and situations. This conference, designed around the theme of “Advancing Patient Safety in Today’s World”, will highlight subjects that include equity and safety, community collaboration, and patient/family engagement.
Institute for Healthcare Improvement.
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next live session is October 27, 2022.
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2022;Epub Aug 10.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Arkin L, Schuermann A, Penoyer D, et al. J Nurs Care Qual. 2022;37:319-326.
Nurses are responsible for several steps in the medication-use process, including preparation, administration, and monitoring of most medications. This study queried nurses working at a 10-hospital system in the southeastern United States about their attitudes, beliefs, and skills surrounding medication safety and error reporting. Survey responses indicate that nurses felt comfortable completing an incident report regarding an error and disclosing the error to another health care provider. There was some ambiguity around rating the severity of hypothetical errors.
Institute for Safe Medication Practices. October 6-7, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Alper E, O'Malley TA, Greenwald J. UpToDate. August 18, 2022.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.