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Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.  
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Patrician PA, Bakerjian D, Billings R, et al. Nurs Outlook. 2022;Epub Jul 4.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
Zipperer L, Ryan R, Jones B. J Patient Saf Risk Manag. 2022;Epub Aug 2.
Implicit biases and stigma can negatively impact health care provided to patients with substance use disorders such as alcohol use disorder (AUD). This narrative review concluded that patients with AUD are frequently undiagnosed and not appropriately referred for treatment or treated. The authors cite barriers to effective care for patients with AUD, including poor integration and coordination between medical care and behavioral health care in the United States.
McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.
Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.  
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
Sabin JA. N Engl J Med. 2022;387:105-107.
Implicit bias in clinicians can result in diagnostic errors and poor patient outcomes. This commentary outlines steps that individual clinicians, as well as healthcare systems, can take to reduce implicit bias and the resulting harm to patients.
Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.
Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.
Packer MDC, Ravinsky E, Azordegan N. Am J Clin Pathol. 2022;157:767-773.
Studies have shown diagnostic discordance in evaluation of surgical pathology specimens. In this study, pathologists and pathology residents were asked to diagnose surgical pathology or cytopathology cases and provide a diagnosis. Most respondents provided the correct diagnosis for most of the cases; 35% of cases were wholly or partially misdiagnosed. Educational and process changes (e.g., requiring subspecialist over-read for some diagnoses) were implemented in the pathology department in response, resulting in substantial improvement in error rates.
Berg SH, Rørtveit K, Walby FA, et al. BMC Health Serv Res. 2022;22:967.
Inpatient suicides are considered a never event. Based on patient and provider interviews and a literature review, this paper describes the development of resilience in inpatient psychiatric settings. The main theme is establishment of relationship of trust between patients and providers.
van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;Epub May 18.
Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;Epub Jul 2.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;Epub Aug 2.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Dionisi S, Giannetta N, Liquori G, et al. Healthcare (Basel). 2022;10:1221.
Medication errors are a global patient safety concern, particularly in high-risk areas like the intensive care unit. This umbrella review synthesizes medication interventions into two areas: systems (e.g., smart pumps) and processes (e.g., medication review). The authors highlight the importance of using multiple strategies when working to improve medication safety in the ICU.
Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 22.
Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).
Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.
Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.
Patel D, Liu G, Roberts SCM, et al. Womens Health Issues. 2022;32:327-333.
Obstetrics is a considered a high-risk care environment. This claims-based retrospective analysis found that abortion-related morbidity or adverse events occurred in nearly 4% of abortions but that event rates did not differ between OBGYNs or physicians of other specialties.