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Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8(4):e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18(1):e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
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.
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2021;Epub Dec 4.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
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.
Bacon CT, McCoy TP, Henshaw DS, et al. J Nurs Adm. 2021;51(11):e20-e26.
Organizational safety climate (OSC) has been associated with positive nurse outcomes. This study compared the association between organizational climate and job enjoyment in two surgical units, one that received crew resource management (CRM) training and the other that did not. The study used the Hospital Culture of Safety framework as a theoretical basis and found that job enjoyment and organizational safety climate scores were higher in the hospitals that received CRM training compared with those that did not.
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26(6):251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2021;Epub Dec 28.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Warner MA, Warner ME. Anesthesiology. 2021;135(6):963-974.
The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.
St.Pierre M, Grawe P, Bergström J, et al. Safety Sci. 2021;147:105593.
The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was a seminal moment in the patient safety movement. This bibliometric analysis found that the report has been mentioned in over 20,000 scientific publications since 2000, but that the themes of recent research do not necessarily align with the initial focus of the IOM report. For example, research on incident reporting and systems approaches to improving safety are underrepresented relative to their emphasis in the IOM report.

Ehrenwerth J. UptoDate. November 5, 2021.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Society to Improve Diagnosis in Medicine.
Diagnostic error is garnering increased attention as a key area of focus in patient safety improvement. This fellowship program for physicians who have completed their residency will provide the opportunity to build expertise in enhancing diagnostic safety. The application process for the 2022-2023 program closes on March 8. 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.
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.
Höcherl A, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18(1):e85-e91.
Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.

Bryant A. UpToDate. September 13, 2021.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
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.