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Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18:e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;Epub Aug 1.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.  
Wiering B, Lyratzopoulos G, Hamilton W, et al. BMJ Qual Saf. 2022;31:579-589.
Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 

Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Graham JMK, Ambroggio L, Leonard JE, et al. Diagnosis (Berl). 2022;9:216-224.
Timely and effective feedback regarding diagnostic errors can reduce future misdiagnosis and prevent overtreatment. Pediatric emergency clinicians were asked about their attitudes towards, and effectiveness of, three diagnostic feedback modalities. Case-based feedback from peers was rated as most likely to improve future practice and none of the modalities was rated as providing emotional support.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.

Leadership commitment is crucial to attaining sustainable improvement in patient safety. This “Declaration to Advance Patient Safety” call-to-action shares three steps to motivate work toward implementing change to enhance safe care. First, commit to a national plan for improvement. Second, identify and empower a senior leader and team to assess an organization’s existent safety status. Third, devise plans to measure, design, implement, and support adverse event reduction initiatives.

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

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.
Verhagen MJ, de Vos MS, Sujan M, et al. BMJ Qual Saf. 2022;31:402-408.
The Safety-II framework uses a proactive approach to improving patient safety by learning form what goes right in healthcare. This article summarizes the attributes of the Safety-II framework and outlines the challenges and opportunities related to integrating Safety-II within healthcare settings.
Wilson C, Howell A-M, Janes G, et al. BMC Health Serv Res. 2022;22:296.
Feedback is an essential component of performance improvement and patient safety. Researchers conducted semi-structured interviews with emergency medical services (EMS) professionals in the United Kingdom about their perspectives on how feedback impacts patient care and safety. Findings highlight strong desire for feedback and concerns that inadequate feedback could inhibit learning from mistakes, limit professional development, and negatively impact patient safety.
Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.
Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.

Quick Safety. February 14, 2022;(64):1-3.

Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices is vital for infection prevention. This newsletter article shares actions to improve infection prevention, including standardized examination processes, infection preventionist involvement, and training focused on the safety impacts of incomplete processing and inappropriate reuse of single use items.

Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.
Adamson L, Beldham‐Collins R, Sykes J, et al. J Med Radiat Sci. 2022;69:208-217.
Reporting of near misses and adverse events can provide a foundation for learning from error. This quality improvement project surveyed radiation oncology staff in two local health districts to assess understanding and use of incident learning systems, barriers to reporting or needs for process change, and perception of departmental safety culture. System processes (e.g., takes too long) were identified as barriers to reporting more frequently than safety culture (e.g., fear of negative action towards self or others).
Sittig DF, Sengstack P, Singh H. JAMA. 2022;327:719-720.
Electronic health records (EHRs) serve an important role in clinical communication improvement while harboring threats to safety if not implemented and used correctly. This commentary discusses elements of a guidance package to enhance EHR safety through a 5-step assessment process.