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Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:B2-B9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.
Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Steffany M. J Healthc Risk Manag. 2022;41:31-38.
Concerns have been raised regarding the need to assess the competencies of aging physicians. This article discusses how different entities (e.g., health systems, states, and professional medical organizations) are addressing this issue through competency-based assessments, peer review, and credentialing requirements.

Joint Commission.

Sentinel events are a primary indicator of patient safety in hospitals that enable learning through reporting to the Joint Commission. This website provides access to statistics, alerts, policies and tools to assist organizations in using sentinel events for their medical error reduction efforts.

Roy CG. Yale J Biol Med. 2021;94(1):165-173. 

Delivery of safe care hinges on the competency of medical professionals. This article outlines the origins of state medical board systems in the United States and their evolving role in promoting patient safety based on IOM recommendations, including re-examination for licensure and specialty board certification, reporting, and monitoring.

Washington DC; Governmental Accountability Office; December 1, 2020. Report no. GAO-21-160R.

Clinicians must receive explicit permission to work in military health system facilities. This report examined the process of monitoring military clinician practice to assure it is safe, reporting mechanisms and procedures in place for addressing concerns with providers should they arise.
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.

Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.
Krupat E, Dienstag JL, Padrino SL, et al. Acad Med. 2020;95.
Unprofessional behavior adversely impacts a culture of safety and can contribute to adverse events. This study compared medical school graduates who appeared before their schools’ review boards for professional-related reasons to matched controls to explore whether professionalism lapses predict problems in residents and clinical practice. Compared with controls, physicians who appeared before their schools’ review boards were more likely to undergo disciplinary review and require remediation or counseling during residency and were more likely to be sued or sanctioned during clinical practice.
Gleason KT, Jones RM, Rhodes C, et al. J Patient Saf. 2021;17:e959-e963.
This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.
de Lima A, Osman BM, Shapiro FE. Curr Opin Anaesthesiol. 2019;32.
Office-based anesthesia (OBA) is being performed more commonly internationally. This narrative literature review updates the evidence related to the safety of OBA and makes recommendations for safe practices including; medical directors to be responsible for evidence-based policies, OBA safety and patient checklists emergency procedures, physical setting requirements, pharmacological management, preoperative procedures, airway management and others. The authors identify that lack of consistent regulations and incomplete protocol standardization is problematic.
Sherwood R, Bismark M. BMJ Qual Saf. 2020;29:113-121.
Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.
Castro-Avila A, Bloor K, Thompson C. J Health Serv Res Policy. 2019;24:182-190.
In the United States, unannounced accreditation inspections are deployed extensively to evaluate hospital safety. This interrupted time-series analysis found that enhanced accreditation procedures in the United Kingdom did not improve rates of either pressure ulcers or falls. In a PSNet interview, the president of The Joint Commission discussed how accrediting bodies can help achieve high reliability.
Srinivasa S, Gurney J, Koea J. JAMA Surg. 2019;154:451-457.
As many as half of all clinicians may be involved in a serious adverse event during their career, and these events may have profound professional consequences. This systematic review examined the effect of patient complications on surgeons' well-being. Patient complications had significant adverse consequences for surgeons' emotional health, to which surgeons responded with coping mechanisms ranging from adaptive (discussing cases with colleagues or utilizing professional support) to maladaptive (alcohol or substance use). Studies reported varying perceptions of institutional support. Many surgeons derived benefit from the support of trusted mentors or senior colleagues after a serious patient complication, but lack of formal organizational support was commonly noted. Surgeons reported taking various corrective actions after a complication, such as personal development and system-level quality improvement efforts. The authors make several recommendations for helping surgeons after complications, including developing formal structures to aid surgeons in the coping process. Books by British neurosurgeon Dr. Henry Marsh and patient safety leader Dr. Atul Gawande explore the professional and personal consequences of adverse events in vivid detail.