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Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8(4):e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Chiel L, Freiman E, Yarahuan J, et al. Hosp Pediatr. 2021;12(1):e35-e38.
Medical residents write patient care orders overnight that are often not reviewed by attending physicians until the next morning. This study used the hospital’s data warehouse and retrospective chart review to examine 5927 orders over a 12-month period, 538 were included in the analysis. Key reasons for order changes included medical decision making, patient trajectory, and medication errors. Authors suggest errors of omission may be an area to direct safety initiatives in the future.
Kämmer JE, Schauber SK, Hautz SC, et al. Med Educ. 2021;55(10):1172-1182.
Checklists are increasingly used to improve diagnosis by supporting clinical decision making and ensuring that all possible diagnoses are considered. This study explored the effect of a prompt to generate alternative diagnoses versus a differential diagnosis checklist on diagnostic accuracy among medical students completing computer-generated patient cases. The researchers found that the checklist improved diagnostic accuracy compared to a prompt, but only if the checklist included the correct diagnosis; if the correct diagnosis was not included on the checklist, diagnostic accuracy was slightly reduced.  
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18(1):e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;Epub Jan 5.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
Etherington C, Kitto S, Burns JK, et al. BMC Health Serv Res. 2021;21(1):1357.
Gender bias has been implicated in negatively affecting patient safety. The authors conducted semi-structured interviews to explore how gender and other social identify factors impact experiences and teamwork in the operating room. Researchers found that women being routinely challenged or ignored or perceived negatively when assertive may hinder their pursuit of leadership positions or certain specialties. Implicit gender bias and stereotypes along with deeply entrenched structural barriers persist and complicate hierarchical relations between professions – all contributing to breakdowns in communication, increased patient safety risks, and poor team morale.  
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2021;Epub Dec 4.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
Lederman J, Lindström V, Elmqvist C, et al. BMC Emerg Med. 2021;21(1):154.
Patients who are treated by emergency medical services (EMS) personnel but not transported to the hospital are referred to as non-conveyed patients. In this retrospective cohort study, researchers found that older adult patients in Sweden are at an increased risk of adverse events (such as infection, hospitalization, or death) within 7-days following non-conveyance.

Ehrenwerth J. UptoDate. November 5, 2021

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Bacon CT, McCoy TP, Henshaw DS, et al. J Nurs Adm. 2021;51(11):e20-e26.
Organizational safety climate (OSC) has been associated with positive nurse outcomes. This study compared the association between organizational climate and job enjoyment in two surgical units, one that received crew resource management (CRM) training and the other that did not. The study used the Hospital Culture of Safety framework as a theoretical basis and found that job enjoyment and organizational safety climate scores were higher in the hospitals that received CRM training compared with those that did not.
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26(6):251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2021;Epub Dec 28.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Warner MA, Warner ME. Anesthesiology. 2021;135(6):963-974.
The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22(12):2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.
St.Pierre M, Grawe P, Bergström J, et al. Safety Sci. 2021;147:105593.
The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was a seminal moment in the patient safety movement. This bibliometric analysis found that the report has been mentioned in over 20,000 scientific publications since 2000, but that the themes of recent research do not necessarily align with the initial focus of the IOM report. For example, research on incident reporting and systems approaches to improving safety are underrepresented relative to their emphasis in the IOM report.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Viscardi MK, French R, Brom H, et al. Policy Polit Nurs Pract. 2022;Epub Jan 6.
Health care work environments can influence safety culture and teamwork. This study used multiyear survey data from registered nurses in 503 hospitals across four states to explore the association between nurse work environment and healthcare quality, patient safety, and patient outcomes. Findings indicate that nurse work environment (such as nurse participation in hospital affairs, nurse manager capability, leadership support, and nurse-physician relationships) is an important factor to improving the experiences of patients and nurses, especially those in hospitals caring for economically disadvantaged patients.