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Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;Epub Aug 24.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.

NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC, American Association of Medical Colleges or virtual; October 3, 2022, 10:00 AM – 12:00 PM (eastern).

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This webinar will discuss the culmination of a six-year effort to design a national multidisciplinary guidance to address system issues that affect the wellbeing of clinicians.
Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.
Wawersik D, Palaganas J. J Healthc Manag. 2022;67:283-301.
Organizational cultures encouraging psychological safety can increase safe healthcare practices such as error reporting. This narrative review identified several organizational factors that promote psychological safety and error reporting (e.g., leadership support, nonpunitive and fair blame cultures, and continuous improvement processes) as well as organizational factors that serve as barriers to reporting (e.g., blame culture, poor communication, burnout, leadership resistance to change).
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.

Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.  SAMHSA Publication No. PEP22-06-02-005.

Behavioral health workers are particularly susceptible to burnout, which sets the stage for unsafe care. This guide highlights organizational strategies to amend six thematic conditions in the behavioral health setting that degrade worker wellbeing: workload; control; reward, promotion, and career development; community; fairness; and values.
Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2022;Epub Aug 19.
Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2022;Epub Aug 22.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.

ISMP Medication Safety Alert! Acute care edition! August 25, 2022:27(17)1-6.

Unanticipated health information system downtime can occur for technical or malicious reasons and healthcare organizations should be prepared for such disruptive events. This article highlights training, planning, simulation, and leadership support as key elements in the successful response to unplanned information system events to manage staff stress and patient safety.
Taylor DJ, Goodwin D. J Med Ethics. 2022;Epub Jul 8.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18:e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).
Gauthier-Wetzel HE. Comput Inform Nurs. 2022;40:382-388.
Barcode medication administration (BCMA) has been promoted as an effective method for reducing medication administration errors. In the emergency department of one Veterans Affairs Medical Center, medication error rates decreased by nearly 11% following introduction of BCMA technology. However, unsafe workarounds were also identified, which may limit the overall safety of BCMA.
Barclay ME. JAMA Health Forum. 2022;3:e221006.
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235:494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.
Kosydar-Bochenek J, Krupa S, Religa D, et al. Int J Environ Res Public Health. 2022;19:9712.
A positive safety climate can improve patient safety and worker wellbeing. The Safety Attitudes Questionnaire (SAQ) was distributed to physicians, nurses, and paramedics in five European countries to assess and compare safety climate between professional roles, countries, and years of healthcare experience. All three groups showed positive attitudes towards patient safety, stress recognition, and job satisfaction; however, overall scores were low.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;Epub Aug 1.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.