Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
The General Assembly of Pennsylvania. HB957 (2005).
This bill calls for a prohibition of mandatory overtime and limiting the work week to 12 hours a day or 60 hours a week for non-supervisory health care employees in Pennsylvania. It is presently under consideration by Pennsylvania's General Assembly.
Clancy CM, Agency for Health Research and Quality; AHRQ.
In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.
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