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Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 22.
Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).

ECRI and the Institute for Safe Medication Practices. September 29, 2022. 12:00pm-5:00pm (EST)

Root cause analysis (RCA) is an established adverse event identification method. This webinar will highlight the importance of a just culture to ensure reporting is robust. It will introduce RCA techniques, patient communication strategies and the importance of appropriate post-analysis response to support improvement.
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.

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Halvorson EE, Thurtle DP, Easter A, et al. J Patient Saf. 2022;Epub Jul 6.
Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
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.
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.

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.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.
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.

J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.