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AHA Training. January 13--February 24, 2022.

Change management skills are important for leaders to implement sustainable safety improvements. This virtual 7-session workshop will use the TeamSTEPPS model to structure organizational approaches for embedding teamwork foundations into processes that support enduring improvement efforts. 
AHA Team Training. January 26--March 30, 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.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation.
Alper E, O'Malley TA, Greenwald J. UpToDate. September 20, 2021.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Healthcare Excellence Canada
This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2021 observance, focusing on the importance of essential care partners, will be held October 25th through 29th.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25(4):492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181(5):610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46(6):1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021;162(5):1379-1386.
Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479(1):47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
Muhrer JC. Nurs Pract. 2021;46(2):44-49.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery, some of which may negatively impact patient outcomes.The authors use a syndemic perspective to discuss existing challenges interfering with diagnosis (structural, socioeconomic, patient-related, and provider-related), how the COVID-19 pandemic has exacerbated those challenges, and strategies related to nurse practitioners and community health workers to improve diagnosis.  

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. 
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18(1):40-45.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.   
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17(1):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.  
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85(Mar):27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.