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Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.
Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.
Smith CJ, DesRoches SL, Street NW, et al. J Healthc Risk Manag. 2022;42:24-30.
New graduate registered nurses (NGRNs) frequently experience a knowledge-practice gap during their transition to practice. This article suggests that the gap has widened, as COVID-19 restrictions impacted pre-licensure nurses’ education, clinical training, testing, and licensure. Recommendations for improving the transition to practice include innovative academic-clinical partnerships.
Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.
While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Institute for Healthcare Improvement. September 14--November 22, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Tajeu GS, Juarez L, Williams JH, et al. J Gen Intern Med. 2022;37:1970-1979.
Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.

Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877.

Patient safety needs to routinely involve new professionals to promote improvement. This publication introduces the foundations of patient safety. It aligns with an established curriculum to enhance learning and engage physicians in the application of safety concepts in their daily practice.

ECRI, Institute for Safe Medication Practices. October 4 and 6, 2022.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to target improvement work. This session will build on a Patient Safety Organization's experience in conducting 450 RCAs to aid participants in leading RCAs and planning implementation strategies to address detected contributors to failure.
Croskerry P. Diagnosis (Berl). 2022;9:176-183.
In dual process thinking, Type 1 decisions are made rapidly, but can result in diagnostic error. Type 2 processing is slower and more deliberate, and typically where novice clinicians begin practice. This article proposes adaptive expertise to improve novices’ processing. Incorporating six strategies (rationality, critical thinking, metacognitive processes, lateral thinking, medical humanities, distributed cognition) in medical education may improve learners’ processing and reduce diagnostic errors.

Collaboration for Better Care. September 13, 2022, Royal Society of Medicine, London, England.

Achieving sustained patient safety improvement is an ongoing goal. This conference will feature a keynote address on the National Health Services’ Patient Safety Strategy and sessions on a variety of patient safety topics including infection prevention and control, remote patient monitoring for patient safety, leadership role in speaking up culture, and learning from patient safety incidents and investigations.
Velasco RAF, Slusser K, Coats H. J Adv Nurs. 2022;Epub Jun 10.
Transgender and gender-diverse may experience poor quality of healthcare due to stigma and discrimination. This systematic review of qualitative studies found that stigma experienced among transgender and gender-diverse patients occurs at the individual (e.g., internalized stigma, marginalization), interpersonal (e.g., verbal abuse from healthcare providers, withholding of care), and structural levels (e.g., gender norms, power imbalances).
Lou SS, Lew D, Harford DR, et al. J Gen Intern Med. 2022;37:2165-2172.
Cross-sectional research has suggested many physicians experience burnout which can negatively impact patient safety. This longitudinal study evaluated the effect of workload (collected via electronic health record audit) on burnout and medication errors (i.e., retract-and-reorder [RAR] events) of internal medicine interns. Higher levels of workload were associated with burnout; there was no statistically significant association between burnout and RAR events.
Drug Enforcement Administration. October 29, 2022.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

National Association for Healthcare Quality. September 12–14, 2022.

Quality and safety improvement efforts need to address intersecting influences to achieve lasting change. This conference will provide content on seven themes that contribute to improvement. Topics discussed specific to patient safety will include culture assessment, safety science, and event reporting.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
Leland NE, Lekovitch C, Martínez J, et al. J Appl Gerontol. 2022;Epub May 26.
Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.