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Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.

Chicago, IL: American Medical Association; February 2022. 

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2021 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 34 percent of the time. 
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur. 

Boston, MA: Institute for Healthcare Improvement: September 2020.  

This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.  

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020. 

Patients and families provide unique insights for leaders working to improve diagnosis. This report highlights how organizations can best implement patient advisory council programs to spark learning, enhance feedback, and support a safety culture that enhances the impact of those efforts. 

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.   

Patient and Family Advisory Councils (PFACs) are an established strategy that provides structure to a health care organization’s patient and family engagement efforts. This report shares insights and tools to establish a PFAC and engage them in diagnostic error reduction.      
Yong E. The Atlantic. 2020;September.
This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.
Kisely S, Warren N, McMahon L, et al. BMJ. 2020;369:m1642.
This meta-analysis examined the psychological effects of viral outbreaks on clinicians and effective strategies to manage stress and psychological distress. The review included 59 studies involving severe acute respiratory syndrome (SARS), COVID-19, Middle East respiratory syndrome (MERS), Ebola and influence. Compared with clinicians at lower risk, those in contact with affected patients had greater levels of both acute and post-traumatic stress, as well as psychological distress. Clinicians were at increased risk for psychological distress if they were younger, more junior, had dependent children, or had an infected family member. Identified interventions to mitigate stress and psychological distress included clear communication, infectious disease training and education, enforcement of infection control procedures, adequate supply of personal protective equipment (PPE) and access to psychological support.
Arora S, Tsang F, Kekecs Z, et al. J Patient Saf. 2021;17:e1884-e1888.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.

Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-248.

Maternal harm is a sentinel event precipitated by a confluence of factors. This report highlights US government and state-level efforts to reduce maternal mortality. Efforts funded through the programs include maternal morbidity review committees and safety bundle use initiatives.
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
Health systems are encouraged to strive for zero preventable harm, but achieving this goal requires a comprehensive, systems-focused effort. This paper discusses the rationale for using ‘zero harm’ as a patient safety goal, and the importance of broadening the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring beyond the hospital and across the care continuum. Four key elements required for successful systems change resulting in safety improvements are discussed: (1) change management, (2) culture of safety, (3) a learning system, and (4) patient engagement and codesign of healthcare.
Cousins D, Accidents A against M.; 2020.
Health care organizations can learn from internal and external incidents to identify potential patient safety risks and incorporate care process improvements. This report suggests that England’s National Health Service has yet to build accountability and reliability into its response to practice alerts. The authors share 4 primary concerns and recommendations to address the alert compliance gaps that focus on clarity on action expected, transparency, communication and monitoring.
Blease CR, Bell SK. Diagnosis (Berl). 2019;6:213-221.
Despite growing support for patient involvement in safety and quality improvement, little is known about engaging patients as partners in reducing diagnostic error. This commentary summarizes research on how sharing notes with patients can improve the timeliness of follow-up to confirm a diagnosis, identify documentation errors, and strengthen communication between the clinical team and the patient. The authors discuss challenges to the successful implementation of this strategy and areas of focus needed for future development. A PSNet interview discussed use of OpenNotes to engage patients in their care.