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1 - 20 of 44

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Soto C, Dixon-Woods M, Tarrant C. Arch Dis Child. 2022;Epub Jul 21.
Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Patient Safety Movement. September 17, 2021. 

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.  
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36:3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18:2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Kaldjian LC. Patient Educ Couns. 2021;104:989-993.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.

Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learning Environments: Pathway Leaders Patient Safety Collaborative. Chicago, IL: Accreditation Council for Graduate Medical Education. September 30, 2020. ISBN: 978-1-945365-36-2.

The clinical learning environment (CLE) situates the development of safety behaviors in resident and fellow physicians, students, and staff. This report highlights results of an 18-month collaborative to design tactics that engage resident and fellows in patient safety work through event analysis. Lessons learned supporting success include assessment of the learner experience and dedication of time to enable participation.   
Dubé MM, Kaba A, Cronin T, et al. Adv Simul (Lond). 2020;5:22.
This article describes the planning and implementation of a multi-site, multidisciplinary simulation program to provide critical just-in-time COVID-19 education in one Canadian province. The authors discuss the unique features and advantages of a centralized simulation response and key themes of the simulation program.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns. 
Musunur S, Waineo E, Walton E, et al. Acad Psychiatry. 2020;44:586-591.
This article describes the impact of an interactive session with second-year medical students utilizing case-based learning, small group discussion, and video vignettes intended to prepare healthcare providers to anticipate and understand the impact of medical errors. Pre- and post-surveys found that this one-hour, small-group session increased medical students’ understanding of the impact of medical errors and adverse events and the resources available to support providers.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
Duhn L, Godfrey C, Medves J. Health Expect. 2020;23:979-991.
This scoping review characterized the evidence base on patients’ attitudes and behaviors concerning their engagement in ensuring the safety of their care. The review found increasing interest in patient and family engagement in safety and identified several research gaps, such as a need to better understand patients’ attitudes across the continuum of care, the role of family members, and engagement in primary care safety practices.
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. Adv Simul (Lond). 2020;5:13.
The authors of this article outline ten recommendations for safely reopening simulation facilities for clinical training in the post-lockdown phase of the COVID-19 crisis. The recommendations are based on national guidance and regulations, as well as international public health recommendations. Future reopening activities should focus on safety as well as flexibility principles, taking different contexts and facility characteristics into account.