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Rogers JE, Hilgers TR, Keebler JR, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 23.
Patient safety investigations hinge on the expertise and experiences of the investigator. This commentary discusses the ways in which cognitive biases can impact patient safety investigations and identifies potential mitigation strategies to improve decision-making processes.
Lipori JP, Tu E, Shireman TI, et al. J Am Med Dir Assoc. 2022;23:1589.e1-1589.e10.
Despite evidence of associated adverse events, older adults in nursing homes are frequently prescribed potentially inappropriate medications (PIM). This review sought to identify facility and prescriber characteristics associated with PIM prescribing. Anti-psychotic medications were the focus of more than half of included studies, and were associated with low registered nurse staffing, for-profit facility status, and younger men. No study investigated prescriber characteristics.
Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.
Lee SE, Hyunjie L, Sang S. West J Nurs Res. 2022;Epub Jul 23.
Effective nurse leadership can result in improved safety climate and willingness to report errors. This review identified 14 studies of the impact of nurse leadership on adverse patient outcomes, rates of nursing errors, error reporting and error reporting intention, quality of care, and patient satisfaction. Transformational leadership in particular showed a positive relationship with improved outcomes.
Eggenschwiler LC, Rutjes AWS, Musy SN, et al. PLoS ONE. 2022;17:e0273800.
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Scott G, Hogden A, Taylor R, et al. Int J Qual Health Care. 2022;34:mzac059.
Healthcare worker engagement is an important indicator of safety culture. This literature review including 15 studies found a positive correlation between engagement and perceptions of patient safety, but research assessing the impact on patient safety outcomes is in its infancy.
Wawersik D, Palaganas J. J Healthc Manag. 2022;67:283-301.
Organizational cultures encouraging psychological safety can increase safe healthcare practices such as error reporting. This narrative review identified several organizational factors that promote psychological safety and error reporting (e.g., leadership support, nonpunitive and fair blame cultures, and continuous improvement processes) as well as organizational factors that serve as barriers to reporting (e.g., blame culture, poor communication, burnout, leadership resistance to change).
Apodaca C, Casanova-Perez R, Bascom E, et al. J Am Med Inform Assoc. 2022;Epub Aug 19.
Minoritized patients who experience implicit or overt discrimination in healthcare report receiving lower quality of care and may avoid seeking care in the future altogether. In this study, patients who identify as Black, Indigenous, People of Color (BIPOC), and/or Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) describe their experiences of unfair treatment and discrimination in healthcare. Four themes related to immediate reactions and six themes related to long-term coping emerged.
Nijor S, Rallis G, Lad N, et al. J Patient Saf. 2022;18:e999-e1003.
Usability issues related to electronic health record (EHR) use among clinicians can contribute to burnout and threaten patient safety. This literature review outlines how EHR usability issues, such as information overload, can lead to errors and threaten patient safety. The authors suggest that future research explore methods to mitigate EHR overload-related errors, including the role of EHR usability.
Dumitrescu I, Casteels M, De Vliegher K, et al. J Patient Saf. 2022;18:435-443.
Medication errors and other adverse events are thought to occur in 10% of home care patients. This Delphi study identified 27 high-risk medications (e.g., oral chemotherapy, anticoagulants) in home care nursing that require a specific procedure and an additional 28 that warrant additional monitoring. Home care agencies and researchers should focus on developing and evaluating policies to improve safety of high-risk medications.
Health Affairs Forefront. 2022;August 26.
The safety of commercial aviation has been a model for health care, yet achieving their level of reliability has been evasive. This piece suggests that weaknesses in voluntary reporting, hazard communication, and human factors design, all of which are core to aviation's success, are contributing to the lack of similar success in health care.
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.

Schulson LB, Thomas AD, Tsuei J, et al.  Santa Monica, CA: RAND Corporation; 2022

Clinical leaders have unique viewpoints on front-line care challenges. This report includes results of an environmental scan and expert interviews that examined how racism, bias, and patient safety intertwine to affect incident reporting, safety culture, and adverse event data collection.
Wallace W, Chan C, Chidambaram S, et al. NPJ Digit Med. 2022;5.
Patient use of digital and online symptom checkers is increasing, but formal validation of these tools is lacking. This systematic review identified ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and ophthalmic conditions. The authors concluded that the diagnostic and triage accuracy of symptom checkers varies and has low accuracy.

National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. Letters of intent are due November 2, 2022.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;Epub Aug 1.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Patrician PA, Bakerjian D, Billings R, et al. Nurs Outlook. 2022;70:639-650.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
Sabin JA. N Engl J Med. 2022;387:105-107.
Implicit bias in clinicians can result in diagnostic errors and poor patient outcomes. This commentary outlines steps that individual clinicians, as well as healthcare systems, can take to reduce implicit bias and the resulting harm to patients.