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Lederman J, Lindström V, Elmqvist C, et al. BMC Emerg Med. 2021;21(1):154.
Patients who are treated by emergency medical services (EMS) personnel but not transported to the hospital are referred to as non-conveyed patients. In this retrospective cohort study, researchers found that older adult patients in Sweden are at an increased risk of adverse events (such as infection, hospitalization, or death) within 7-days following non-conveyance.
Eiding H, Røise O, Kongsgaard UE. J Patient Saf. 2022;18(1):e315-e319.
Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43(5):1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
O’Connor P, O’Malley R, Lambe KA, et al. Int J Qual Health Care. 2021;33(4):mzab138.
Patient safety incidents occurring in prehospital care settings are gaining increasing attention. This systematic review including both peer-reviewed studies and grey literature found that the incidence rate of prehospital patient safety incidents is similar to hospital rates. The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients occurring in prehospital care; approximately 15% of these incidents resulted in patient harm. The authors discuss methodological challenges to preshopital care research and make recommendations for future studies.
Ali A, Miller MR, Cameron S, et al. Pediatr Emerg Care. 2021;Epub Oct 26.
Interhospital transfer of critical care patients presents patient safety risks. This retrospective study compared adverse event rates between pediatric patient transport both with, and without, parent or family presence. Adverse event rates were not significantly impacted by parental presence.
Paulin J, Kurola J, Koivisto M, et al. BMC Emerg Med. 2021;21(1):115.
Emergency medical services (EMS) personnel are in the unique position of providing medical care outside of a healthcare facility. This prospective cohort study conducted in Finland explored the outcomes of patients who were treated by EMS personnel without going to the ED. Findings indicate that 80% of patients treated by EMS did not have any re-contact with the healthcare system (e.g., re-contacted EMS, went to the ED, were hospitalized), suggesting that EMS management of these patients is relatively safe.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
Fostering a positive safety culture is essential to delivery of safe care. This mixed-methods study of nurses and non-physician health professionals found that staff perceptions of senior leadership, teamwork, and turnover intention were significantly associated with overall patient safety grade.

American College of Emergency Physicians, National Association of Emergency Medical ServicesAnn Emerg Med. 2021;78(3):e37-e57. 

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.
Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2021;Epub Jul 14.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Hu X, Casey T. J Adv Nurs. 2021;77(9):3733-3744.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.
Osei-Poku G, Szczerepa O, Potter A, et al. Patient Safety. 2021;3(3):6-17.
This mixed-methods study examined the experiences of home healthcare workers in Massachusetts during the COVID-19 pandemic. Participating home care workers noted that the lack of necessary resources (e.g., PPE, testing) and insufficient guidance specific to home care settings made their working conditions feel unsafe.
Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4(8):e2123007.
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17(6):458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Hoyle JD, Ekblad G, Woodwyk A, et al. Prehosp Emerg Care. 2021:1-8.
Inaccurate assessment of pediatric patient weight can lead to medication dosing errors. In simulated pediatric scenarios, pre-hospital emergency medical services (EMS) crews obtained patient weight using one or more of three methods: asking parent, using patient age, and Broselow-Luten Tape (BLT). BLT was the most frequent method used and patient age resulted in the most frequent dosing errors. Systems-based solutions are presented.
Jakonen A, Mänty M, Nordquist H. Jt Comm J Qual Patient Saf. 2021;47(9):572-580.
Checklists have been implemented in a variety of specialties and settings to improve safe patient care. In this study, researchers developed and pilot-tested safety checklists for emergency response driving (ERD) and patient transport in Finland. Semi-structured interviews with paramedics and ERD drivers indicated that the safety checklists improved perceived safety.
Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;Epub May 13.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Zimmer M, Czarniecki DM, Sahm S. PLoS One. 2021;16(5):e0250932.
Inadequate team communication is a marker of poor safety culture and can threaten patient safety. This survey of 714 medical and non-medical emergency medical services (EMS) employees in Germany found nearly three-quarters of respondents had been involved in a patient harm incident and that deficits in team communication were a primary contributor.  
Fuller G, Pandor A, Essat M, et al. J Trauma Acute Care Surg. 2021;90(2):403-412.
Prehospital triage tools are used to differentiate between patients who need emergency care at a major trauma center (MTC) and those that may receive adequate care at a non-MTC.  Accurate triage tools are necessary to ensure that patients are not over- or undertriaged. This review found high variability in sensitivity and specificity across geriatric triage tools indicating some patients may not be receiving the specialized trauma care they need. The authors highlight several future research targets including development of relevant reference standards and balancing the risk between over- and undertriage.
Sedlár M. Int J Occup Saf Ergon. 2021;Epub Mar 19.
Stress and fatigue experienced by healthcare workers can threaten patient safety. This survey of 131 emergency medical services (EMS) crew members identified a relationship between work-related factors (e.g., stress, fatigue), unsafe behavior, and safety incident involvement. Reducing stress and fatigue and improving cognitive skills, including situation awareness, can improve compliance with safe behaviors.