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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.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
Wolfe HA, Mack EH. Transl Pediatr. 2018;7:267-274.
Pediatric critical care patients are at greater risk for harm. This review examines how a culture of safety affects pediatric critical care delivery and highlights collaboratives as effective mechanisms to develop and test improvement strategies. The authors discuss the development of bundles to reduce hospital-acquired infections and standardize handoffs as promising safety improvement practices.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2015;29:340-6.
Clinical staff often fail to call rapid response teams to evaluate deteriorating patients, even when objective criteria for calling the team are met. This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture of safety can result in failure to use the rapid response team when appropriate and can also lead to using the team as a workaround to compensate for poor interdisciplinary communication.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

Baker GR, ed. Healthc Q. 2010;13(Spec No):1-136.  

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Werner RM, McNutt RA. JAMA. 2009;301.
The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.
Bagnara S; Tartaglia R; Wears RL; Perry SJ; Salas E; Rosen MA; King H; Carayon P; Alvarado CJ; Hundt AS; Healey AN; Vincent CA; Falzon P; Mollo V; Friesdorf W; Buss B; Marsolek I; Barach P; Bellandi T; Albolino S; Tomassini CR.
This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team management, work design, and safety culture.
Matlow A; Laxer RM; Morath JM; Sharek PJ; Classen D; Keatings M; Martin M; McCallum A; Lewis J; Stevens P; Harrison C; Scanlon MC; Karsh BT; Densmore EM; Luria JW; Muething SE; Schoettker PJ; Kotagal UR; Parshuram CS; Kozer E; Berkovitch M; Koren G; Lehmann C; Kim GR; Streitenberger K; Breen-Reid K; Harris C; Flores G; Ngui E; Dunn KL; Moulden A; McDougall P; Bowes G; Curley MAQ; Schwalenstocker E; Deshpande JK; Ganser CC; Bertoch D; Brandon J; Kurtin P; Stevens P.
This special issue examines patient safety through the perspectives of parents, hospital leadership, human factors experts, and clinicians.

Healthc Q. 2006;9 Spec No:1-140.

This special issue describes projects and research in Canadian health care that are supporting improvements in patient safety.