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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.
Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
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).

Washington, DC: Leapfrog Group; July 2022.

Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This report recommends strategies that support systemic work toward diagnostic excellence and selected implementation stories that illustrate success. It is a part of a larger initiative devoted to the improvement of organizational and team activities in tandem with clinical processes to minimize the impact of human error on diagnosis.
Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.
Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.
Patel D, Liu G, Roberts SCM, et al. Womens Health Issues. 2022;32:327-333.
Obstetrics is a considered a high-risk care environment. This claims-based retrospective analysis found that abortion-related morbidity or adverse events occurred in nearly 4% of abortions but that event rates did not differ between OBGYNs or physicians of other specialties.

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.
Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.
Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.
Upadhyay S, Opoku-Agyeman W, Choi S, et al. J Public Health Manag Pract. 2022;28:505-512.
Patient engagement is a key element of successful patient safety improvement efforts, including those leveraging health information technology (IT) approaches. This longitudinal study using a national sample of hospitalizations identified a significant association between patient engagement and electronic health record (EHR) adoption with the incidence of adverse events.
Ostrow O, Prodanuk M, Foong Y, et al. Pediatrics. 2022;150:e2021055866.
Appropriate antibiotic prescribing is a core component of antibiotic stewardship programs to reduce the risk of antibiotic-resistant microbes. This study assessed the rate of misdiagnosed pediatric urinary tract infections (UTI) and associated antibiotic use following implementation of a quality improvement intervention. Using three interventions (diagnostic algorithm, callback system, standardized discharge antibiotic prescription), misdiagnosis of UTI decreased by half, and 2,128 antibiotic days were saved.

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.
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;Epub Jul 25.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.

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.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;Epub Jun 30.
Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.
Wiering B, Lyratzopoulos G, Hamilton W, et al. BMJ Qual Saf. 2022;31:579-589.
Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
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.
Harrison R, Johnson J, McMullan RD, et al. J Patient Saf. 2022;Epub May 25.
Providers who are involved in a medial error may experience a range of negative emotions and utilize a variety of coping mechanisms following the error. The authors update their 2010 systematic review on medical professionals’ coping with medical error and apply their Recovery from Situations of Error Theory (ReSET) model. The ReSET model provides a basis to develop and evaluate interventions to reduce feelings of distress and increase providers’ coping skills.