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St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Farrell TW, Butler JM, Towsley GL, et al. Int J Environ Res Public Health. 2022;19:5975.
A robust culture of safety encourages open communication between team members. Certified nursing assistants (CNAs) and nurses in nursing homes were asked about the extent to which their input about residents was valued by the other team members. CNAs reported they felt valued by other CNAs and nurses, but less valued by physicians and pharmacists.
Kepner S, Adkins JA, Jones RM. Patient Safety. 2022;4:6-17.
Residents at long-term care facilities are at increased risk for healthcare-associated infections. Using 2021 data from the Pennsylvania Patient Safety Reporting System (PA-PRS), this study characterized healthcare-associated infections (HAIs) occurring at long-term care facilities. Researchers found that HAIs occurring at long-term care facilities decreased, but it is unknown whether this is reflective of fewer infections or poor reporting practices at long-term care facilities, or both.
Leland NE, Lekovitch C, Martínez J, et al. J Appl Gerontol. 2022;Epub May 26.
Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.  

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Niederhauser A, Schwappach DLB. Health Sci Rep. 2022;5:e631.
Ensuring that healthcare staff feel comfortable speaking up about safety concerns is an important component of safety culture. This cross-sectional study explored speaking up behaviors and perceptions among healthcare workers in rehabilitation clinics in Switzerland. Barriers to speaking up included expectations of a lack of productive response to the safety concern, presence of patients, and concerns about reactions from involved individuals.

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.
Lefosse G, Rasero L, Bellandi T, et al. J Patient Saf Risk Manag. 2022;27:66-75.
Reducing healthcare-acquired infections is an ongoing patient safety goal. In this study, researchers used structured observations to explore factors contributing to healthcare-related infections in nursing homes in one region of Italy. Findings highlight the need to improve the physical care environment (e.g., room ventilation), handwashing compliance, and appropriate use of antibiotics.
Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, et al. Int J Environ Res Public Health. 2022;19:3423.
Inappropriate prescribing and polypharmacy can place older adults at increased risk for medication-related adverse events. This study found that up to 90% of older adults had at least one inappropriate prescription, regardless of residential setting but medication review resulted in a greater decrease in risk factors for medication-related adverse events (e.g., polypharmacy, therapeutic complexity) among nursing home patients compared to patients living at home.
Rotenstein LS, Melnick ER, Sinsky CA. JAMA. 2022;327:2079-2080.
Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
Díez R, Cadenas R, Susperregui J, et al. Int J Environ Res Public Health. 2022;19:4313.
Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Fischer SH, Shih RA, McMullen TL, et al. J Am Geriatr Soc. 2022;70:1047-1056.
Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process. 

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259

Nursing homes face significant patient safety challenges, and these challenges became more apparent during the COVID-19 pandemic. This report identifies key issues in the delivery of care for nursing home residents and provides recommendations to strengthen the quality and safety of care delivery, such as improved working conditions, enhanced minimum staffing standards, improving quality measurement, and strengthening emergency preparedness.

Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.

Improving diagnosis and reducing diagnostic errors are patient safety priorities. This announcement supports the development of Diagnostic Centers of Excellence focused on improving frontline diagnostician support and improving diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference standards). Applications are due by June 9, 2022.
Paulik O, Hallen J, Lapkin S, et al. J Patient Saf. 2022;18:e613-e619.
Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).
Willis E, Brady C. Nurs Open. 2022;9:862-871.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).