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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
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.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;Epub Jul 21.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
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.
Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;15:28-41.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Alboksmaty A, Beaney T, Elkin S, et al. The Lancet Digital Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Wade C, Malhotra AM, McGuire P, et al. BMJ. 2022;376:e067090.
The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.

Health information technologies (HIT) and advanced learning systems, if poorly designed, used, maintained, integrated, or accessed, harbor the potential for failure across the systems they support. This legal discussion argues for federal standards to establish levels of accountability for physicians who use HIT systems and assign liability, should use result in patient harm.
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Hartstein B, Munante M, Toor PA. NEJM Catalyst. 2022;3:e1-e20.
High-reliability organizations (HROs) are able to “manage the unexpected” while operating under challenging conditions. This article describes the U.S. Medical Department’s systemwide rollout of the Top Six HRO communication practices. The authors summarize how the Top Six campaign was developed and discuss the implementation of six systemwide initiatives to increase reliability – (1) daily safety briefings; (2) safety leadership rounds; (3) unit-based huddles; (4) Situation Background Assessment Recommendation (SBAR) for communication; (5) briefs and debriefs for surgical cases; and (6) Universal Protocol before every procedure.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;Epub Jan 28.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.
Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.