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Jones LA. The Philadelphia Inquirer. July 17, 2022.

Racial disparities and inequities detract from safe maternal care. This feature article discusses the history of obstetric care in the United States and examines the roots of unsafe care for Black mothers that perpetuate in that community today.

Medication orders with future start dates: how far away Is too far?

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Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.

Human errors that occur while interacting with electronic health record (EHR) systems can impact patients. This article discusses a keystroke error that delayed the scheduling of an antibiotic for one year. Recommendations to mitigate the potential for similar errors include risk assessment, hard stop use, and daily medication review.

Provider implicit bias: bringing awareness to clinical practice.

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Moss LD. Clinical Advisor. June 29, 2022.

Health disparities perpetuated by structural racism degrade patient safety. This article discusses the influence of implicit biases on care delivery and highlights the increased interest and research being generated to improve understanding and initiative design to reduce the impact of implicit bias on care.

Stop using these adult bed rails, warns the Consumer Product Safety Commission.

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Treisman R. National Public Radio. June 6, 2022

Bedrails are used in hospitals and at home to minimize falls despite the potential to contribute to patient harm. This news article summarizes a government recall of ten models of home bed rail devices due to entrapment incidents.

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

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Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

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ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

‘Almost like malpractice’: to shed bias, doctors get schooled to look beyond obesity.

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Sausser L. Kaiser Health News. May 24, 2022.

Lack of education contributes to misunderstandings and unhelpful preconceptions. This article discusses biases affecting the care of patients who are overweight. It introduces an educational effort to raise awareness of potential diagnostic and treatment actions affected by clinician bias to decrease safety for this patient population.

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

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ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

4 actions to reduce medical errors in U.S. hospitals.

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Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Woman works to end Black maternal health crisis after daughter dies after giving birth.

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Kindelan K. ABC News. April 14, 2022.

Maternal injury is a persistent challenge in the Black community. This article discusses the case of one mother whose discounted health concerns contributed to diagnostic delay and death. The piece shares social media tools to assist Black mothers in keeping themselves safe during pregnancy and after birth.

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

Patients should know who's operating, surgeons say.

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Laber-Warren E. MedPage Today. April 5, 2022.

Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news article highlights situations where resident autonomy should be disclosed to patients (such as instances of overlapping surgeries) and the value of transparency about the role of surgical team members.

Nurses: Guilty verdict for dosing mistake could cost lives.

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Loller T. Associated Press. March 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Dying for Care.

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Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

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