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Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;Epub Sep 8.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.
Van Slambrouck L, Verschueren R, Seys D, et al. J Prof Nurs. 2021;37(4):765-770.
An online survey of nursing students in Belgium found that about one in three students were involved in a patient safety incident during their clinical training, and the majority experienced emotional distress after the event. Medical and nursing curriculum should include opportunities for competency development to support peers involved in patient safety incidents.
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4(8):e2123007.
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8(3):333-339.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. This qualitative study explored patients’ perspectives on the diagnostic process of endometriosis. Findings suggest that the diagnosis of endometriosis is hindered by delayed consultation, inadequate understanding and appraisal of symptoms by general practitioners, and inadequate communication between patients and providers.
Grundgeiger T, Hurtienne J, Happel O. Hum Factors. 2020;63(5):821-832.
The usability of information technology continues to be a challenge in health care. The authors suggest that consideration of the user is critical to improving interaction with technology and thus increasing patient safety. They provide a theoretical foundation for considering user experience in healthcare.
Papaioannou AI, Bartziokas K, Hillas G, et al. Postgrad Med. 2021;133(5):524-529.
Incorrect use of medical devices can lead to unfavorable outcomes. In this study of 663 patients with asthma and/or chronic obstructive pulmonary disease (COPD), 41% demonstrated incorrect use of their inhaler. Incorrect use was more common among older patients and associated with more acute exacerbations.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17(6):e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Res Social Adm Pharm. 2021;17(8):1426-1432.
This multicenter prospective study explored the effect of medication reconciliation on patient-reported, potential adverse events post-discharge. Although the intervention – which consisted of a pharmacy team providing patient both education and medication review upon admission and discharge as well as information transfer to primary care – did not decrease the proportion of patients with adverse events, it did reduce the number of potential adverse events.
Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. Ann Surg. 2021;274(1):114-119.
Resilience is the process of identifying and overcoming unexpected adverse events. By reviewing video, audio, and patient physiologic data recorded during 24 laparoscopic surgeries, researchers were able to identify safety threats and resilience supports used to overcome them. Of the six category codes, (person, task, tools and technology, physical environment, organization, and external environment) most safety threats and supports were in the person category.
Blum MR, Sallevelt B, Spinewine A, et al. BMJ. 2021;374:n1585.
Older adults with multimorbidity and polypharmacy are at increased risk of adverse drug events. This cluster randomized controlled trial compared drug-related hospitalization rates of older adults who received a structured deprescribing intervention and those who received usual care. While rates of polypharmacy decreased, there was no effect on drug-related hospitalizations.

Geneva: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity
Hackenberg EAM, Sallinen V, Handolin L, et al. J Interpers Violence. 2021;36(15-16):7832-7854.
Victims of intimate partner violence (IPV) may seek care at emergency departments. This study of self-reporting IPV victims found that while serious injuries were rare, many victims had suffered extreme violence and approximately half had risk factors for re-abuse. Fewer than 20% were referred to victim advocacy resources.
Hernández-Prats C, López-Pintor E, Lumbreras B. Res Social Adm Pharm. 2021;Epub Jul 12.
Clinical pharmacists play an important role in ensuring patient safety, particularly in interventions aimed at reducing polypharmacy. This review focused on interventions involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure. Findings indicate interventions are most successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure medications are followed.
Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149(4):846-853.
Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;Epub Jul 22.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
van der Kooi T, Lepape A, Astagneau P, et al. Euro Surveill. 2021;26(23).
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality every year. Three mortality review measures were developed to measure the potential contribution of HAIs to patient death. All three measures showed acceptable feasibility, validity, and reproducibility in HAI surveillance.
Kappes M, Romero‐García M, Delgado‐Hito P. Int Nurs Rev. 2021;Epub Jun 13.
Healthcare professionals who experience negative physical, psychological, or behavioral responses following an adverse event may be referred to as “second victims.” This review describes personal and organizational support strategies as well as barriers faced by second victims who are seeking support. The authors recommend further evaluation of support programs and implementation of support programs in Latin America.