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AORN J. 2022;115:454-457.
This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Dionisi S, Di Simone E, Liquori G, et al. Public Health Nurs. 2021;Epub Dec 31.
Causes of medication errors occurring in home care may differ from those in the hospital setting. This systematic review identified three main risk factors for medication errors in the home: transition documentation, medication reconciliation, and communication among the multidisciplinary team. Most studies recommend involvement of a pharmacist as a member of the care team.

National Academy of Medicine.

Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This educational program will draw from the 2015 Institute of Medicine Improving Diagnosis in Health Care report to support a multidisciplinary cohort of scholars to advance diagnostic improvement. The application process for the 2022-2023 class is open until March 3, 2022.

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
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.
NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health.

Alper E, O'Malley TA, Greenwald J. UpToDate. September 30, 2021.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. Epub 2021 Jul 6. 

 

Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.