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Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;Epub Apr 22.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Tham N, Fazio T, Johnson D, et al. World J Surg. 2022;46:1249-1258.
The COVID-19 pandemic led to changes in infection control and prevention measures to limit nosocomial spread. This retrospective cohort study found that escalations in infection prevention and control practices due to the COVID-19 pandemic did not affect the incidence of other hospital-acquired infections among surgical patients at one Australian hospital. The authors posit that this may be due to high compliance with existing infection prevention and control practices pre-pandemic.
Paulik O, Hallen J, Lapkin S, et al. J Patient Saf. 2022;18:e613-e619.
Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).
Patel TK, Patel PB, Bhalla HL, et al. Eur J Clin Pharmacol. 2022;78:267-278.
Adverse drug events are common and often result in preventable patient harm. Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related deaths contributed to 5.6% of all inpatient hospital deaths. The authors estimated that almost half of drug-related deaths are preventable.
Mimmo L, Harrison R, Travaglia J, et al. Dev Med Child Neurol. 2022;64:314-322.
Children with intellectual disabilities may experience poor-quality care and be at higher risk for patient safety events. This cross-sectional study including patients admitted to two children’s hospitals in Australia found that children with intellectual disabilities had longer hospital stays and experienced more admissions with at least one clinical incident (e.g., medication incidents, documentation errors) compared to children without intellectual disabilities.
Alanazi FK, Sim J, Lapkin S. Nurs Open. 2022;9:30-43.
Nurse attitudes towards patient safety culture have shown to impact missed nursing care, iatrogenic harm, and other adverse events. This review synthesizes research on nurses’ safety attitudes and subsequent impact on patient outcomes. While most data on adverse events was self-reported, nurses indicated an improved safety culture resulted in fewer reported adverse events. Nurse managers can play an important role in improving patient safety culture and outcomes in their hospital units.
Hada A, Coyer F. Nurs Health Sci. 2021;23:337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Schulz-Moore JS, Bismark MM, Jenkinson C, et al. Jt Comm J Qual Patient Saf. 2021;47:376-384.
Error disclosure is critical to improving communication and patient safety. This article describes the development and pilot testing of the Medical Injury Reconciliation Experiences Survey (MIRES). The final 40-item survey addresses patient and/or family perceptions of communications with healthcare providers after the injury, perceptions of remedial gestures, overall satisfaction with the reconciliation process, the nature and impacts of the injury, and patient characteristics.
Stevens EL, Hulme A, Salmon PM. Ergonomics. 2021;64:1072-1090.
Power dynamics can influence effective team performance and patient safety. This systematic review examined the influence of actual or perceived ‘power’ on teamwork within multidisciplinary healthcare settings. Findings indicate that power imbalances can result in negative effects on team collaboration, decision-making, communication, and performance. An April 2020 WebM&M commentary discusses the effect of power dynamics on interprofessional healthcare teams.
Lane AS, Roberts C. BMJ Simul Technol Enhanc Learn. 2021;7:345-351.
Open disclosure by healthcare providers is increasingly encouraged. This qualitative study characterized the experiences of medical students participating in a high-fidelity simulation session based on open disclosure after medication error. Findings reinforced the need for psychological safety, emotional arousal during learning, and both individual and collective reflective learning.
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;34:580-586.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication.

Berry D, Wakefield E, Street M, et al. J Adv Nurs. 2020;76:2235-2252.
Isolation for infection prevention and control is beneficial but may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events). This systematic review did not identify any evidence suggesting that adult patients in isolation precautions for infection control are more likely to experience clinical deterioration or hospital-acquired complications compared to non-insolated patients.
Anderson N, Thompson K, Andrews J, et al. J Med Radiat Sci. 2020;67:243-248.
This article describes the delivery of radiation therapy services during the COVID-19 pandemic at one cancer center in Australia, and the risk mitigation strategies used to enhance continuity of care while minimizing the risk of infection among patients and healthcare workers. 
Johnson CD, Green BN, Konarski-Hart KK, et al. J Manipulative Physiol Ther. 2020;43:403.e1-403.e21.
An international sample of chiropractic practitioners described actions taken by their practices in response to the COVID-19 pandemic. Practitioners discuss using innovative strategies such as telehealth to continue providing patient-centered care while complying with local regulations.
Tartari E, Saris K, Kenters N, et al. PLoS One. 2020;15.
Presenteeism among healthcare workers can lead to burnout and healthcare-associated infections, but prior research has found that significant numbers of healthcare workers continue to work despite having influenza-like illness. This study surveyed 249 healthcare workers and 284 non-healthcare workers from 49 countries about their behaviors when experiencing influenza-like illness between October 2018 and January 2019. Overall, 59% of workers would continue to work when experiencing influenza-like illness, and the majority of healthcare workers (89.2-99.2%) and non-healthcare workers (80-96.5%) would continue to work with mild symptoms, such as a mild cough, fatigue or sinus cold.  Fewer non-healthcare workers (16.2%) than healthcare workers (26.9%) would continue working with fever alone.
Nowotny BM, Davies-Tuck M, Scott B, et al. BMJ Qual Saf. 2021;30:186-194.
After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.
Safer Care Victoria and Victorian Agency for Health Information.
Large scale tracking of adverse care incidents offers evidence that governments and organizations can use to target care process improvement efforts. This Website houses content from a partnership of two Australian organizations to collect, analyze submitted incident data to work directly with constituents to improve quality and safety across the system.
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.