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Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.

Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796. 

Surveys are recognized tools to inform hospitals of the current status of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Hospital Survey on Patient Safety Culture Comparative Database data collection process. The deadline for submitting comments on this notification is August 2, 2022.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
Oregon Patient Safety Commission.
This annual Patient Safety Reporting Program (PSRP) publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2021 data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon.
Ong N, Mimmo L, Barnett D, et al. Dev Med Child Neurol. 2022;Epub May 16.
Patients with intellectual disabilities may be at higher risk for patient safety events. In this study, researchers qualitatively analyzed hospital incident reporting data and identified incidents categories disproportionately experienced by children with intellectual disabilities. These incident categories included medication-intravenous fluid issues, communication failures, clinical deterioration, and care issues identified by parents.
Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18:342-350.
Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.

Burton É, Flores B, Jerome B, et al. JAMA Netw Open. 2022;5(5):e2213234.

Disruptive clinician behavior is a recognized patient safety concern. This study used reports submitted to the internal patient safety reporting system to explore potential implicit bias in the types and severity of reports filed against physicians. Results showed women and minoritized physicians were disproportionately reported for low-severity issues such as communication, while men and white physicians were more likely to be reported for the highest severity level. Findings suggest a lower threshold for submitting reports against women and minoritized physicians which may be due to implicit bias.
Luty JT, Oldham H, Smeraglio A, et al. Acad Med. 2022;97:529-535.
Improving student and resident education and involvement in quality improvement and patient safety is a goal of graduate medical education. Researchers at Oregon Health & Science University developed a simulation-based medical education curriculum for multidisciplinary residents and fellows. The pilot cohort reported significantly improved reactions, attitudes and confidence, and knowledge and skills.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;Epub Apr 30.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

Grimm CA. Washington DC: Office of the Inspector General; May 2022. Report no. OEI-06-18-00400.

In its 2010 report, the Office of the Inspector General (OIG) found 13.5% of hospitalized Medicare patients experience harm in October 2008. This OIG report has updated the proportion of hospitalized Medicare patients who experienced harm and the resulting costs in October of 2018. Researchers found 12% of patients experienced adverse events, and an additional 13% experienced temporary harm. Reviewers determined 43% of harm events could have been prevented and resulted in significant costs to Medicare and patients.
Bhakta S, Pollock BD, Erben YM, et al. J Hosp Med. 2022;17:350-357.
The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;Epub Apr 21.
Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.
Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Feng T-ting, Zhang X, Tan L-ling, et al. J Nurs Adm. 2022;52:160-166.
When reported and investigated, near misses provide a unique learning opportunity for individuals and organizations. This scoping review of the literature on near misses identifies contributing factors (organizational, human, and technical); barriers and facilitators to reporting; and quality improvement projects to improve reporting of near misses.

Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.