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Monazam Tabrizi N, Masri F. BMJ Open. 2021;11(8):e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.
Lopez-Pineda A, Gonzalez de Dios J, Guilabert Mora M, et al. Expert Opin Drug Saf. 2021:1-11.
Medication administration errors made by parent or caregivers can result in medication errors at home. This systematic review found that 30% to 80% of pediatric patients experience a medication error at home, and that the risk increases based on characteristics of the caregiver and if a prescription contains more than two drugs.
Foster C, Doud L, Palangyo T, et al. Pediatr Qual Saf. 2021;6(4):e434.
Healthcare worker safety has been linked to overall safety culture. A pediatric hospital adapted patient safety event reporting infrastructure and definitions to worker safety reporting. Implementation of the worker safety reporting system reduced time from injury to reporting, identified safety gaps, and improved worker satisfaction with the reporting process.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;Epub May 23.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Ziemba JB, Berns JS, Huzinec JG, et al. Acad Med. 2021;96(7):997-1001.
Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.
Dynan L, Smith RB. Health Serv Outcomes Res Methodol. 2021.
Peer review is one strategy for assessing clinical performance and uncovering potential safety issues. Based on hospital discharge and expenditure data from 2004 – 2015 in Florida, the authors found a significant beneficial effect of increased hospital expenditure on peer review and patient safety outcomes.

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.

Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is December 10, 2021.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174(7):927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
de Vos MS, Hamming JF, Marang-van de Mheen PJ. J Patient Saf. 2021;17(3):231-238.
Morbidity and mortality (M&M) conferences are a useful tool for teams to investigate and learn from adverse events. In this observational study, researchers interviewed clinicians attending surgical M&M conferences to explore the types, and recurrence of, lessons learned. Clinicians ascribed most lessons to technical or individual-level issues, and observed the challenges to sustaining changes at a systems-level. Researchers suggest M&M formats should shift to a broader focus to implement and sustain lasting system-level improvements.
Wehkamp K, Kuhn E, Petzina R, et al. BMC Med Ethics. 2021;22(1):26.
Clinicians are often confronted by ethical issues during the delivery of care. The authors outline four categories of critical incidents relevant to biomedical ethics – (1) patient-related communication, (2) consent, autonomy, and patient interest, (3) conflicting economic and medical interests, and (4) staff communication and corporate culture. The authors suggest that integrating these dimensions into existing incident reporting system processes (e.g., training risk managers and nurses to identify ethical incidents, involving an ethnical committee or specialists for clinical ethical consultations) may increase ethical behavior, patient safety, and employee satisfaction.     
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2021.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2020 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication efforts, and the convening of patient safety conferences for the state.
Institute for Safe Medication Practices.
These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2021–2022 fellowships closed March 31, 2021.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.  

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure. 
Singh H, Carayon P. JAMA. 2020;324(24):2481-2482.
Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.   
Marshall TL, Ipsaro AJ, Le M, et al. Pediatrics. 2021;147(1):e20192400.
Missed or delayed diagnoses can lead to treatment delays and worse outcomes. This article describes a quality improvement intervention intended to improve physician reporting of suspected diagnostic errors affecting pediatric patients. Intervention components included a standardized reporting process and a systematic feedback and evaluation process, as well as efforts to increase physician engagement, awareness, and psychological safety.  

Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.

Challenges beset safe care delivery for indigenous peoples. This report examines factors contributing to adverse events in this patient population. Recommendations for improvement include an emphasis on harm monitoring and incident reporting. A related report examines the lack of application of maternity best practices in the Indian Health Service.
Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11(3):e256-e262.
Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.