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Healthcare Excellence Canada
This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2022 observance will be held October 24th through 28th.

US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct 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.

Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.
Joint Commission, National Quality Forum.
The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application procedure. The deadline for submitting an application for the 2022 award cycle is September 14, 2022.

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Agency for Healthcare Research and Quality. 

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.

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.
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.

The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Washington DC: Office of the Surgeon General; May 2022.

Health care staff and clinician wellbeing is known to affect safety and quality. This advisory suggests national priorities to target improvement efforts. Areas of focus include workforce shortages, system inequities and burnout.

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

A strong safety culture affects practice and learning in health care. This survey of over 1,000 clinicians and staff in 110 medical offices examined the extent to which elements of safety culture support safe diagnosis. Key findings demonstrate strengths in specialist consultation and test result communication. Identified weaknesses included lack of discussions about misdiagnoses when they occurred.
Rockville, MD: Agency for Healthcare Research and Quality; 2019.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey and accompanying toolkit were developed to collect opinions of hospital staff on the safety culture at their organizations. An accompanying database serves as a central repository for hospitals to report their results. Participating hospitals will be able to measure patient safety culture in their institutions and compare results with other sites. Data will be collected for the latest submission period from June 1–July 22, 2022.

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.
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; May 18, 2022.
This guidance outlines design elements that reduce errors associated with medication labels. Improvements suggested include tall-man lettering use, look-alike / sound alike avoidance and abbreviation minimization.

Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.

Rockville, MD; Agency for Healthcare Research and Quality: April 2022.

TeamSTEPPS promotes effective teamwork, collaboration, and communication in health care while focusing on strategies known to improve patient safety. This challenge competition seeks submissions to revise existing TeamSTEPPS videos to improve health literacy, equity, and cultural sensitivity. Written proposals are due June 20, 2022.

Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.