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Kostick-Quenet KM, Cohen IG, Gerke S, et al. J Law Med Ethics. 2022;50:92-100.
Biases in decision support technologies precipitate racial inequities. This commentary discusses how algorithms in machine learning contribute to inaccuracies in the care of persons of color and the displaced. Legal actions to mitigate racial biases in decision making programs and implementation steps toward improvement are discussed.
Peivandi S, Ahmadian L, Farokhzadian J, et al. BMC Med Inform Decis Mak. 2022;22:96.
Speech recognition software is a potential strategy to reduce documentation burden and burnout. This study compared the accuracy handwritten nursing notes versus online and offline speech recognition software. Findings indicate that the speech recognition software was accurate but created more errors than handwritten notes.

Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.
Yesmin T, Carter MW, Gladman AS. BMC Health Serv Res. 2022;22:278.
Advanced technology – such as radiofrequency identification (RFID), sensors, or mobile apps – is increasingly used to improve patient safety. This study explored whether the use of “internet of things” (i.e., network of physical objects – “things” – that are embedded with sensors, software or other technology to connect and exchange data with other devices, such as RFID technology) is effective at reducing patient falls and improving hand-hygiene compliance.
Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 27, 2023.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2022;64:6-20.
Safe diagnosis is a complex challenge requiring multidisciplinary approaches. The authors of this article apply high-reliability organization principles to the National Academy of Medicine (NAM) diagnostic process. The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams and organizations can use to optimize the diagnostic process and improve patient outcomes.
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.  
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.  
Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38:1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Capolongo S, Gola M, Brambilla A, et al. Acta Biomed. 2020;91(9-s):50-60. 
Based on qualitative data gathered through hospital observations, public health webinars, and expert working groups, the authors propose ten strategies for creating critical care surge capacity and designing resilient hospital facilities to prevent and contain COVID-19 infections. Strategies include strategic site location, functional programs, heating, ventilation, air conditioning, indoor air quality, and digital innovation.
Park S-H, Stockbridge EL, Miller TL, et al. PLoS One. 2020;15:e0235754.
This study merged inpatient discharge data with annual survey data from the American Hospital Association and found that private patient rooms were significantly associated with fewer hospital-acquired MRSA infections; however the effect of private rooms is disproportionate across hospitals. Hospitals with fewer private rooms stand to see the greatest decrease in MRSA infections from adding additional private rooms. These findings can assist hospital administrators making decisions about facility design and renovation.