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Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.

Grimm CA. Washington DC: Office of the Inspector General; May 2022. Report no. OEI-06-18-00400.

In its 2010 report, the Office of the Inspector General (OIG) found 13.5% of hospitalized Medicare patients experience harm in October 2008. This OIG report has updated the proportion of hospitalized Medicare patients who experienced harm and the resulting costs in October of 2018. Researchers found 12% of patients experienced adverse events, and an additional 13% experienced temporary harm. Reviewers determined 43% of harm events could have been prevented and resulted in significant costs to Medicare and patients.
Bhakta S, Pollock BD, Erben YM, et al. J Hosp Med. 2022;17:350-357.
The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;Epub Apr 1.
Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.
Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.

Institute for Healthcare Improvement.

Crisis management skills are valuable at both the organizational and clinical levels. This curated set of materials supports leadership engagement in the proactive development and implementation of crisis management plans as a part of larger culture of safety efforts. Key elements covered support respectful communication with patients, families and clinicians after medical errors occur.
Ozimek JA, Greene N, Geller AI, et al. Am J Perinatol. 2022;39:307-311.
Maternal morbidity and mortality remains a major public health concern, particularly among pregnant people of color. This US hospital established a multi-disciplinary committee, the obstetric Quality and Peer Review Committee (OBQPRC), to review all cases of severe maternal morbidity (SMM). This article compares the pre- and post-intervention periods to determine if rates of potentially preventable SMM decreased. While there was no difference in SMM rates pre- and post-intervention, the rate of potentially preventable events significantly decreased after implementation of routine review of all SMM.  
Hamad DM, Mandell SP, Stewart RM, et al. J Trauma Acute Care Surg. 2022;92:473-480.
By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Gunderson CG, Rodwin BA. J Hosp Med. 2022;17:399-402.
The Institute of Medicine’s (IOM) report To Err is Human: Building a Safer Health System estimated that medical errors contributed to 44,000 to 98,000 deaths in the US. This commentary argues the estimates included in the IOM and other studies are overestimated, and that patient safety advocates should shift the focus from estimating deaths due to medical error to preventing patient harm due to hospital-acquired infections, procedural complications, medication errors, and diagnostic errors  

Rau J. Kaiser Health News. February 8, 2022. 

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.
Myren BJ, de Hullu JA, Bastiaans S, et al. Health Commun. 2022;37:191-201.
Understanding patient and provider preferences and perspectives is essential to effective error disclosure. This review explored the perspectives of patients and healthcare professionals involved in disclosure communication. Findings suggest that factors influencing effective disclosure occur on three levels: interpersonal skills (e.g., communication, adaptability, tailored communication, and creating space for emotions), organizational practices (e.g., prompt disclosure, private spaces, supporting patients to report errors), and supportive factors (e.g., disclosure training, culture of openness).
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.