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Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.
Dunbar NM, Delaney M, Murphy MF, et al. Transfusion. 2021;61(9):2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.

Washington Patient Safety Coalition. October 6-7, 2021.

This annual virtual conference will highlight regional and local experiences driving improvement in health equity, diagnostic safety, and patient engagement. Sidney Dekker and John D. Banja are among the speakers.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.

Institute for Healthcare Improvement. Dallas TX. May 16-18, 2022. 

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics which include the continuum of care, learning systems and leadership.
Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;Epub Jun 13.
The goal of the patient centered medical home (PCMH)  model is to reorganize primary care to provide team-based, coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety concerns (e.g., medication safety, diagnostic error, treatment delays, communication or coordination errors) in the context of the PCMH model and explore variability in the implementation of patient safety practices.
Holden RJ, Carayon P. BMJ Qual Saf. 2021;30(11):901-910.
Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.
Bentley SK, McNamara S, Meguerdichian MJ, et al. Adv Simul (Lond). 2021;6(1):9.
Debriefing is a communication strategy for teams to improve patient safety by learning from critical events, reducing reoccurrences, and improving processes. The authors developed and pilot-tested a debriefing tool to broaden the traditional focus of debriefs from “what went wrong” to also include what went right. In three debriefs conducted without the new tool, teams discussed an average of 14 topics; in three debriefs using the new tool, an average of 21 topics were discussed.  The authors propose debriefing when things go right will increase debriefings overall.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2021:001872082199618.
Safe diagnosis is a complex challenge requiring multidisciplinary approaches. The authors of this article apply high-reliability organization principles to the National Academy of Medicine (NAM) diagnostic process. The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams and organizations can use to optimize the diagnostic process and improve patient outcomes.

Boston Children’s Hospital. April 15, 2021. 

A core tenant of patient safety improvement is to draw from the experiences of a range of high-risk industries to address system safety barriers. This session focused on adaptations that health care has made in response to the COVID-19 pandemic. Dr. Don Berwick is among the featured speakers.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106(4):326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Janes G, Mills T, Budworth L, et al. J Patient Saf. 2021;17(3):207-216.
The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  
Komashie A, Ward JR, Bashford T, et al. BMJ Open. 2021;11(1):e037667.
A systems approach is a key element in safe patient care. This systematic review concluded that a systems approach to healthcare design and delivery can lead to significant improvements in patient and service outcomes (e.g., fewer delays for appointments and time-to-treatment).  

Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.   

Patient misidentification errors have the potential for serious patient harm. This study analyzed the processes of care involved in 1,189 wrong-patient events. Most errors occurred during ordering/prescribing (42%). One-quarter of all events reached the patient, most commonly involving inappropriate medication administration or receiving the wrong test or procedure. Errors caught before reaching the patient were primarily attributed to information review by nurses, technicians, or other healthcare staff. The authors recommend several strategies for reducing wrong-patient errors. 
Abreu Saurin T. Safety Sci. 2027;134:105087.
The COVID-19 pandemic has raised new challenges and opportunities for quality improvement and safety science.The authors use a complexity thinking (understanding the dynamic interactions between systems) perspective to discuss the pandemic as a safety science problem with corresponding risk mitigation measures.

Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71. 

 

Human factors approaches have been identified as one of the primary vehicles to create lasting patient safety innovation. Articles in this special supplement examine the role of human factors engineering and ergonomics in establishing improvement in organizational learning, pandemic response, and primary care management. 
Ebm C, Carfagna F, Edwards S, et al. J Crit Care. 2020;62:138-144.
Prescribing medications for indications that are not approved by the Food and Drug Administration (FDA) is common but poses a risk for medication errors. The authors of this study used simulation modeling to explore the influence of physician personal preference on off-label medication use during the COVID-19 pandemic.  
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33(1):mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Int J Qual Health Care. 2021;33(1):mzaa151.
Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.