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Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
AHA Team Training. September 22 -- November 17, 2022.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes. 

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.

AHA Team Training.
 

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.   
Diaz MCG, Dawson K. Am J Med Qual. 2020;35:474-478.
Communication and shared mental models are key elements to effective teamwork. This study explored whether simulation-based closed-loop communication training would improve staff perceptions of communication ability and decrease medical errors. Increases in perception of closed-loop communication ability were sustained one-month after training. A retrospective chart review of all emergency severity index (ESI) level 1 patients (n=9) seen in the 4-months pre- and post-training showed a reduction in medical errors (89% to 56%, respectively).
Manges K, Groves PS, Farag A, et al. BMJ Qual Saf. 2020;29:499-508.
Teamwork Shared Mental Models (SMM) reflect the teams’ understanding of its members’ roles and interactions. This mixed-methods study examined teamwork-SMMs during discharge and described the differences of discharge teams with higher versus lower teamwork-SMMs. Teams with better teamwork-SMMs during discharge were more likely to report similar understanding of the patient’s situation, open communication and exchange of information, and team cohesion and resulted in more effective care delivery. Poor team-SMMs were characterized by divergent opinions regarding patient care plans, delays or gaps in communication, and team members operating independently and in isolation from their team.
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Lewis KA, Ricks TN, Rowin A, et al. Worldviews Evid Based Nurs. 2019;16:389-396.
Simulation is an active learning methodology being used in hospitals to improve patient care.  Results of this systematic review that focused on acute care nurse simulation training and patient safety outcomes indicate that simulation training can be effective for improving patient safety outcomes in this context; the authors note, however, that additional high–quality research is needed to support this field.
Given BA. Semin Oncol Nurs. 2019;35:374-379.
Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.
Simpkin AL, Murphy Z, Armstrong KA. Diagnosis (Berl). 2019;6:269-276.
Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).
Duke Center for Healthcare Safety and Quality.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2019;38:44-54.
This pre–post study examined the implementation of AHRQ's TeamSTEPPS training program. Investigators found that the intervention had positive effects on staff ratings of teamwork and patient satisfaction, and these improvements persisted for one year.

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.