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1 - 20 of 309

Safer Care for All. London, England:  Professional Standards Authority for Health and Social Care; 2022.

Dedicated leadership is an important component to examine and address challenges to safety across a system. This report outlines a process to reduce the complexity of care across the United Kingdom through the establishment of offices to address inequity, emerging risk regulation, workforce issues, accountability, and lack of trust in the system.

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.
St Paul, MN: Minnesota Department of Health.
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 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877.

Patient safety needs to routinely involve new professionals to promote improvement. This publication introduces the foundations of patient safety. It aligns with an established curriculum to enhance learning and engage physicians in the application of safety concepts in their daily practice.

Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887. 

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.
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.
Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. 

Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

Geneva, Switzerland; World Health Organization; May 5, 2022.

Healthcare-acquired infection is a persistent systemic problem. This report recaps the universal status of infection prevention and control (IPC) programs and highlights the influence of nosocomial infection on care provision and public health. The examination states that concerning IPC disparities exist in low-income countries. It reviews the impact of poor infection control, cost-effectiveness of existing efforts, and recommendations to improve and sustain IPC efforts worldwide.

Arnetz JE. Jt Comm J Qual Patient Saf. 2022;48(4):241-245.

Patient violence toward health care workers is a common, yet underreported, influence on care safety. This commentary summarizes policies in place to address patient violence and highlights Joint Commission standards developed to reduce the potential for violence in care environments. Improved reporting, organizational engagement, and safety culture development are among the strategies recommended.

Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.

Bias in any form degrades the safety and effectiveness of communication and care. This report summarizes data documenting the impact of racial and ethnic discrimination on older adult patients. It provides recommendations that include increasing content in medical school curriculum to raise awareness of biased medical care and tailoring communication needs to ethnic communities as steps toward reducing discrimination.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.

Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. 

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.

Chicago, IL: American Medical Association; February 2022. 

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2021 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 34 percent of the time. 

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.