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Chiel L, Freiman E, Yarahuan J, et al. Hosp Pediatr. 2021;12(1):e35-e38.
Medical residents write patient care orders overnight that are often not reviewed by attending physicians until the next morning. This study used the hospital’s data warehouse and retrospective chart review to examine 5927 orders over a 12-month period, 538 were included in the analysis. Key reasons for order changes included medical decision making, patient trajectory, and medication errors. Authors suggest errors of omission may be an area to direct safety initiatives in the future.
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.
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.
Etherington C, Kitto S, Burns JK, et al. BMC Health Serv Res. 2021;21(1):1357.
Gender bias has been implicated in negatively affecting patient safety. The authors conducted semi-structured interviews to explore how gender and other social identify factors impact experiences and teamwork in the operating room. Researchers found that women being routinely challenged or ignored or perceived negatively when assertive may hinder their pursuit of leadership positions or certain specialties. Implicit gender bias and stereotypes along with deeply entrenched structural barriers persist and complicate hierarchical relations between professions – all contributing to breakdowns in communication, increased patient safety risks, and poor team morale.  
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.
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.
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.
Viscardi MK, French R, Brom H, et al. Policy Polit Nurs Pract. 2022;Epub Jan 6.
Health care work environments can influence safety culture and teamwork. This study used multiyear survey data from registered nurses in 503 hospitals across four states to explore the association between nurse work environment and healthcare quality, patient safety, and patient outcomes. Findings indicate that nurse work environment (such as nurse participation in hospital affairs, nurse manager capability, leadership support, and nurse-physician relationships) is an important factor to improving the experiences of patients and nurses, especially those in hospitals caring for economically disadvantaged patients.

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
Marr R, Goyal A, Quinn M, et al. BMC Health Serv Res. 2021;21(1):1330.
Many hospitals are implementing programs to support clinicians involved in adverse events (‘second victims’). Researchers interviewed 12 representatives of second victim programs in the United States about the experiences of their programs. The article discusses representative feedback regarding the importance of identifying a need for second victim programs and services, perceived challenges to program success, structural changes after program implementation, and insights for success.   
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.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi: 

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. A related webinar will be held February 2, 2022.
Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2021;Epub Nov 24.
Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.