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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.
Kämmer JE, Schauber SK, Hautz SC, et al. Med Educ. 2021;55(10):1172-1182.
Checklists are increasingly used to improve diagnosis by supporting clinical decision making and ensuring that all possible diagnoses are considered. This study explored the effect of a prompt to generate alternative diagnoses versus a differential diagnosis checklist on diagnostic accuracy among medical students completing computer-generated patient cases. The researchers found that the checklist improved diagnostic accuracy compared to a prompt, but only if the checklist included the correct diagnosis; if the correct diagnosis was not included on the checklist, diagnostic accuracy was slightly reduced.  
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.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22(12):2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.
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.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;Epub Jan 3.
A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

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.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.
Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.
This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.
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. 

Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.  

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.
Stahl K, Groene O. PLoS ONE. 2021;16(12):e0259252.
Patient safety in ambulatory care is an emerging focus of measurement and improvement efforts. This cross-sectional study including patients from 22 ambulatory care practices in Germany found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors discuss how different approaches to voluntary reporting can influence measurement of patient experience.
Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2021;Epub Nov 18.
Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.
Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71(713):e931-e940.
In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.
Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2021;Epub Oct 30.
In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21(7):618.
Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.