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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.
Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;Epub Jun 9.
Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47(9):591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Spencer RA, Singh Punia H. Patient Educ Couns. 2021;104(7):1681-1703.
Communication failures during transitions of care can threaten safe patient care. Although this systematic review identified several tools to support communication between inpatient providers and patients during transitions from hospital to home, the authors did not identify any existing tools to support the post-discharge period in primary care.
Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2(1):63.
Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.
Strid EN, Wåhlin C, Ros A, et al. BMC Health Serv Res. 2021;21(1).
Based on semi-structured interviews with healthcare workers in Sweden, the authors explored how individuals, team members and managers respond to critical incidents. Critical incidents are emotionally distressing for healthcare workers but teamwork and trust among teams can facilitate safe practices and help individuals overcome emotional distress. Respondents also highlighted the importance of organizational support for managing risks, individual closure, and providing support after an incident.
Louch G, Albutt AK, Harlow-Trigg J, et al. BMJ Open. 2021;11(5):e047102.
Prior research found that patients with learning disabilities (e.g., autism, attention deficit disorder, Down’s syndrome) face numerous patient safety threats. In this narrative review, the authors synthesized academic and grey literature exploring patient safety outcomes for individuals with learning disabilities in acute care settings. Findings suggest that individuals with learning disabilities experience poorer patient outcomes but that increasing family and caregiver engagement as well as provider understanding of the needs of people with learning disabilities can improve outcomes.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30(7):525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.

ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.

Concentrated potassium chloride is a high-alert medication for which dosing errors are particularly injurious. This article shares the root causes of IV-push missteps with this medication during a code. Recommendations for improvement shared center on team characteristics and communication.
Walters GK. J Patient Saf. 2021;17(4):e264-e267.
The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.
Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.
This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include  improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.
Killin L, Hezam A, Anderson KK, et al. Jt Comm J Qual Patient Saf. 2021;47(7):438-451.
Medication errors at hospital discharge are a common cause of medication errors and adverse drug events (ADE). This review compared three types of discharge medication reconciliation: paper-based, electronic, and enhanced. Results suggest electronic medication reconciliation reduced the odds of a medication discrepancy or ADE, as compared to paper-based. Results were mixed on enhanced medication reconciliation.
Sharma V, Kulkarni V, Eurich DT, et al. BMJ Open. 2021;11(5):e043964.
Opioids are high-risk medications and a significant source of patient harm. Using administrative data for over 390,000 adult patients in Alberta, Canada, who received an opioid prescription from 2017-2018, the authors developed machine learning models to estimate the 30-day risk of opioid-related adverse outcomes. Findings suggest that incorporating hospitalization or physician claims into the models can improve predictive performance, as compared to the inclusion of guidelines or prescribing history alone.
Vanhaecht K, Zeeman G, Schouten L, et al. J Nurs Manag. 2021;Epub Apr 25.
Peer support programs can help clinicians cope with the emotional consequences of involvement in an adverse event. This cross-sectional survey of Dutch nurses and doctors found that most respondents (86%) had been involved in a patient safety incident at some point during their career but only a small proportion sought out support in the aftermath of the incident.

Patient Safety Movement Foundation. 2021. 

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;Epub Mar 26.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.
Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Shahian DM. BMJ Qual Saf. 2021;30(10):769-774.
The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.
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.