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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.
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Lopez-Jeng C, Eberth SD. Health Promot Pract. 2020;21:918-925.
Patient falls are an ongoing source of preventable harm. This article describes the implementation of an innovative employee-based education program for falls prevention. The program included information on organizational strategies for safety assessment and individual-level changes, such as patient communication, safe patient handling, and how to report and learn from patient falls.
Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
Parush A, Wacht O, Gomes R, et al. J Med Internet Res. 2020;22:e19947.
This study surveyed healthcare professionals in Israel and Portugal to identify key human factors that influence the use of personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19. Respondents attributed difficulties in wearing PPE to discomfort, challenges in hearing and seeing, and doffing. Analyses also found an association between PPE discomfort and situational awareness, but this association reflected difficulties in communication (e.g., hearing and understanding speech).
Imach S, Eppich WJ, Zech A, et al. Simul Healthc. 2020;15.
This case study describes the use of root cause analysis to investigate a critical incident occurring during an emergency medicine simulation scenario, and discusses the importance of these investigations in furthering the training of emergency medicine personnel and instructors.

Ellis B, Hicken M. CNN. May 14, 2020.

Long-term care and skilled nursing facilities care for a patient population particularly vulnerable to COVID-19 infection. This article discusses an analysis of a large nursing home system and gaps in its workforce safety program. Problems highlighted included communication practices that fall short of what is needed to assure staff safety as they care for nursing home residents.
Hemsley B, Steel J, Worrall L, et al. J Safety Res. 2019;68:89-105.
This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.
Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Robotics are increasingly used to assist in both complicated and routine activities in health care. Although safety hazards associated with robotic technologies have been explored in surgery, risks related to purely assistive devices is understudied. This review highlights clinician perspectives regarding assistive robots in health care and highlights infection control and reliability issues as concerns associated with their use.
Leone RM, Adams RJ. Rehabil Nurs. 2016;41:26-32.
Inpatient falls are a pervasive sentinel event that require improvements in processes and the environment to achieve sustainable reductions. This commentary discusses how engaging nurse leadership in fall prevention efforts in a rehabilitation unit decreased fall rates and sustained this improvement by promoting a culture of safety.
Clark C. HealthLeaders Media. September 18, 2014.
This news article explores the validity of recent reports by an interdisciplinary consortium that one in three hospitalized patients is malnourished and suggests further research is required to understand this potential patient safety problem.
American Society for Parenteral and Enteral Nutrition; ASPEN.
This Web site includes a toolkit, posters, and educational materials to support safe tube feedings and prevent tubing misconnections. 
After removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn.
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.