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Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4(12):e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2021;Epub Nov 30.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Benning S, Wolfe R, Banes M, et al. J Pediatr Nurs. 2021;61:372-377.
Patient falls represent a significant cause of patient harm. While most research on falls focus on the in-patient setting, this study reviewed research evidence and findings from environmental assessments to provide recommendations for reducing risk of falls in the pediatric ambulatory care setting. Three categories of barriers and interventions were identified: equipment and furniture, environment, and people.
Svensson J. J Patient Saf. 2021;Epub Aug 5.
Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance – (1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerized methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence, and falls.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18(15):7780.
Informed environmental features, such as the built environment, can improve safety outcomes. The authors propose a theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization, People, and Environment) intended to synthesize design interventions into a systems-based model using the principles of human factors and ergonomics.
Mikos M, Banas T, Czerw A, et al. Int J Environ Res Public Health. 2021;18(15):8167.
Patient falls resulting in injury are considered a never event. In this analysis of falls within one hospital, rates and trends varied across six clinical departments. The highest rate of falls was seen in rehabilitation and internal medicine, and the lowest rate in orthopedic and rheumatology. Clinical department, rates, and trends should be considered when implementing fall prevention strategies.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2021;Epub Aug 14.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18(14):7581.
Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77(8):3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17(4):273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  
Hada A, Coyer F. Nurs Health Sci. 2021;23(2):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.
Kepner S, Jones RM. Patient Safety. 2021;3(2):6-21.
Acute healthcare facilities in Pennsylvania are required to report all events of harm or potential harm to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Of all submitted events in 2020, 97% were from hospitals, and 97% were incidents; 3 percent were serious events. The most common event was Error Related to Procedure/Treatment/Test (32%). There was a 5.3% decrease from the prior year in the number of reported events, indicating the COVID-19 pandemic had an impact on reporting activity.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36(10):3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Thomas AN, Balmforth JE. J Patient Saf. 2021;17(2):e71-e75.
Patient falls represent a serious source of preventable harm. The authors reviewed patient safety incidents in critical care units in England between 2009 and 2017 and found that a small proportion (2%) involved a fall. Common factors involved in fall incidents included patients attempting tasks without assistance, patient confusion, and staff being away from the patient. Harm to patient or staff occurred in 22% of falls.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2021.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2020 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication efforts, and the convening of patient safety conferences for the state.