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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33(4):mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 
Theobald KA, Tutticci N, Ramsbotham J, et al. Nurse Educ Pract. 2021;57:103220.
Simulation training is often used to develop clinical and nontechnical skills as part of nursing education.  This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.
Ang D, Nieto K, Sutherland M, et al. Am Surg. 2021;Epub Nov 12.
Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality.  Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).
Groves PS, Bunch JL, Sabin JA. J Clin Nurs. 2021;30(23-24):3385-3397.
While many studies have been conducted on implicit bias in healthcare, a gap exists in nurse-specific bias and impact on disparities. This scoping review identified 215 research reports on nurse bias and/or care disparities. Most were descriptive in nature and only 12 included evaluating an intervention designed to reduce nurse-related bias. Recommendations for future research include development and testing of interventions designed to reduce nurse-related bias.
Shojania KG. Jt Comm J Qual Patient Saf. 2021;47(12):755-758.
Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26(5):200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

Joseph A. Stat News. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28(13):8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Hinkley T‐L. J Nurs Scholarsh. 2021;Epub Nov 7.
Clinicians can experience adverse psychological consequences after making a mistake. This survey of 1,167 nurses found that social capital (both alone and in combination with psychological capital) has a significant impact on the severity of these adverse psychological outcomes.
Henderson M, Han F, Perman C, et al. Health Serv Res. 2021;Epub Oct 15.
With the goal of improving allocation of scarce care coordination resources in primary care, this study utilized Medicare fee-for-service claims data to identify risk factors to identify individuals at risk of future avoidable hospital events. Risk factors in six domains were identified: diagnosis, pharmacy utilization, procedure history, prior utilization, social determinants of health, and demographic information.

Jacksonville University.

Inspired by the research and leadership of Dr. Robert Wears, this award annually recognizes individuals, teams or organizations that examine the applications of safety science concepts to improve medicine. The deadline for submitting a 2022 award nomination is January 3, 2022.
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.
Phillips R  A, Schwartz RL, Sostman HD, et al. NEJM Catalyst. 2021;2(12).
This article summarizes the principles of high reliability organizations (HROs) and how one healthcare organization sought to become an HRO by emphasizing a culture of safety and the learning healthcare system. The authors discuss how the principles of high-reliability were successfully leveraged during the COVID-19 pandemic.

Bergl PA, Nanchal RS, eds. Diagnostic Excellence in the ICU: Thinking Critically and Masterfully. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43(5):1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
Walshe N, Ryng S, Drennan J, et al. Int J Nurs Stud. 2021;124:104086.
Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.
Hoang R, Sampsel K, Willmore A, et al. CJEM. 2021;23(6):767-771.
The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED discharge were analyzed to determine if the deaths were anticipated or unanticipated and/or due to medical error. Rates of unanticipated death due to medical error were low, however clinicians should consider related patient, provider, and system factors.
Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2021;Epub Oct 8.
Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.
Seufert S, de Cruppé W, Assheuer M, et al. BMJ Open. 2021;11(11):e052973.
Patient reports of patient safety incidents are one method to detect safety hazards. This telephone survey of German citizens found that patients frequently report patient safety incidents back to their general practitioner or specialist and these incidents can lead to loss of trust in the physician.