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1 - 20 of 1977
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
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.
Smith CJ, DesRoches SL, Street NW, et al. J Healthc Risk Manag. 2022;42:24-30.
New graduate registered nurses (NGRNs) frequently experience a knowledge-practice gap during their transition to practice. This article suggests that the gap has widened, as COVID-19 restrictions impacted pre-licensure nurses’ education, clinical training, testing, and licensure. Recommendations for improving the transition to practice include innovative academic-clinical partnerships.

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Institute for Healthcare Improvement. September 14--November 22, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Tajeu GS, Juarez L, Williams JH, et al. J Gen Intern Med. 2022;37:1970-1979.
Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.

ECRI, Institute for Safe Medication Practices. October 4 and 6, 2022.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to target improvement work. This session will build on a Patient Safety Organization's experience in conducting 450 RCAs to aid participants in leading RCAs and planning implementation strategies to address detected contributors to failure.

Collaboration for Better Care. September 13, 2022, Royal Society of Medicine, London, England.

Achieving sustained patient safety improvement is an ongoing goal. This conference will feature a keynote address on the National Health Services’ Patient Safety Strategy and sessions on a variety of patient safety topics including infection prevention and control, remote patient monitoring for patient safety, leadership role in speaking up culture, and learning from patient safety incidents and investigations.
Lou SS, Lew D, Harford DR, et al. J Gen Intern Med. 2022;37:2165-2172.
Cross-sectional research has suggested many physicians experience burnout which can negatively impact patient safety. This longitudinal study evaluated the effect of workload (collected via electronic health record audit) on burnout and medication errors (i.e., retract-and-reorder [RAR] events) of internal medicine interns. Higher levels of workload were associated with burnout; there was no statistically significant association between burnout and RAR events.

National Association for Healthcare Quality. September 12–14, 2022.

Quality and safety improvement efforts need to address intersecting influences to achieve lasting change. This conference will provide content on seven themes that contribute to improvement. Topics discussed specific to patient safety will include culture assessment, safety science, and event reporting.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
Leland NE, Lekovitch C, Martínez J, et al. J Appl Gerontol. 2022;Epub May 26.
Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.  

National Patient Safety Board. 2021-2022.

Patient safety expertise builds on a wide range of subjects to inform progress. This webinar series features discussions on topics spanning concerns that impact effective care delivery such as peer evaluation, systemic failures, human factors, and big data. A June 2022 discussion guide accompanies the series to support conversation and reflection.

Massachusetts Health and Hospital Association. July 13, 2022, 12:00 PM (eastern).

Systemic improvement strategies can be leveraged to address overarching issues affecting health care quality such as safety, timeliness, and equity, given how lasting solutions must consider a wide range of factors to ensure success. This webinar will examine holistic approaches to align established safety initiatives to enhance equity efforts.

Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application deadline is July 31, 2022.
Center for Patient and Professional Advocacy. October 28-29, 2022; W Atlanta Downtown, Atlanta, GA.
Disruptive behaviors reduce teamwork to degrade the safety of care delivery. This workshop will outline a three-step process to identify professionals with problematic behaviors and design actions to address them. The session will feature Gerald B. Hickson as an instructor. 

CHPSO. July 13, 2022 - 2:00 PM – 3:00 PM (eastern). 

Health care is recognizing that diagnostic accuracy is a team activity. This session will highlight the importance of teamwork in diagnosis and the role of the team leader to ensure safe diagnosis. The discussion will focus TeamSTEPPS strategies to improve diagnostic safety.
Bicket MC, Waljee JF, Hilliard P. JAMA Health Forum. 2022;3:e221356.
Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.