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Gregory H, Cantley M, Calhoun C, et al. Am J Emerg Med. 2021;46:266-270.
Medication safety continues to be a challenge in most healthcare settings, including emergency departments. In this academic emergency department, an overall error rate of 16.5% was observed, including errors in directions, quantity prescribed, and prescriptions written with refills. Involving a pharmacist at discharge may increase patient safety.
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2021;Epub Sept 13.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.
Barber Doucet H, Ward VL, Johnson TJ, et al. Clin Pediatr (Phila). 2021;60(9-10):408-417.
Healthcare provider implicit biases can lead to inequitable care delivery and poorer patient outcomes. Pediatric residents were surveyed about their attitudes, skill level, and preferred educational interventions related to implicit bias and care of diverse populations. Prior medical education or training in diversity and bias-related skills was associated with higher self-reported skill level.
Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.
Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.

Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.
Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96(9):1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;Epub Jul 30.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17(6):e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.
Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;Epub Aug 31.
Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.
D'Angelo JD, Lund S, Busch RA, et al. Surgery. 2021;170(2):440-445.
This study evaluated the type and effectiveness of resident and faculty coping strategies following an intraoperative error and the interaction with physician gender. Results show that while men and women surgeons experience adverse events at approximately the same rate, the coping methods utilized and effectiveness of the methods varied.
Wang X, Wilson C, Holmes K. J Gerontol Soc Work. 2021:1-17.
Nursing home residents are especially vulnerable to COVID-19 due to their age and communal living conditions. Using publicly available data for nursing homes in Florida, this study explored the association between nursing home characteristics and COVID-19 cases and deaths. Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status, facility size and average occupancy rate, rather than quality (as measured by infection prevention and control deficiencies).
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Davidson JE, Chechel L, Chavez J, et al. Am J Crit Care. 2021;30(5):375-384.
Nurses play a critical role in ensuring patient safety. Following the Joint Commission’s revised standards for titration of continuous intravenous medications, 730 nurses were surveyed about their experiences. Based on 159 comments, two overarching themes were identified: harms (e.g., erosion of workplace wellness, moral dilemma, patient safety) and professionalism (e.g., autonomy, nurse proficiency).
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17(6):458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.

Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.
Cohen JB, Patel SY. Anesth Analg. 2021;133(3):816-820.
Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;Epub Sep 3.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
Preston-Suni K, Celedon MA, Cordasco’s KM. Jt Comm J Qual Patient Saf. 2021;47(10):673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic