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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.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2022;78:2015-2029.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Walters GK. J Patient Saf. 2021;17:e264-e267.
The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.
Shahian DM. BMJ Qual Saf. 2021;30:769-774.
The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.
Reeves JJ, Ayers JW, Longhurst CA. J Med Internet Res. 2021;23:e24785.
The COVID-19 pandemic has led to an extraordinary increase in the use of telehealth. This article discusses unintended consequences of telehealth and outlines guidance to assist health care providers in determining the appropriateness of a telehealth visit.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  

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. 
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
Shah C, Sanber K, Jacobson R, et al. J Grad Med Educ. 2020;12:578-582.
Standardized handoff tools can reduce adverse events among hospitalized patients. This retrospective cohort study found that the I-PASS handoff tool’s illness severity assessment can identify patients at higher risk of overnight clinical deterioration and rapid response team (RRT) activation. Patients who were flagged as being at risk for higher levels of care or whose illness trajectory was uncertain were significantly more likely to have an overnight RRT activation compared with stable patients. The authors suggest that this approach can help overnight residents prioritize patient care.  
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.  

Dolan J, Mejia B. Los Angeles Times. September 30, 2020.

Socioeconomic conditions influence access to health care, and as a result, reduce its safety and reliability. This story describes how inequity can affect the care of disadvantaged patient populations and shares data on wait times for specialty care in Los Angeles County that contributed to costly diagnostic and treatment delays.

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.

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.   
Sauro KM, Soo A, de Grood C, et al. Crit Care Med. 2020.
Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.

SB 3380. 116th Congress (2020).

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.