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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Willis E, Brady C. Nurs Open. 2022;9:862-871.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).
Horsham, PA: Institute of Safe Medication Practices; 2021
Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

United Kingdom.

Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;128:542-549.
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Mayo Clin Proc. 2020;95:1842-1844.
This article discusses the threat that the “flexibilization” of science has played during the COVID-19 pandemic, defined as the loosening of methodological standards leading to low-quality studies, and resulting in unreliable data and anecdotal evidence.
Coleman JJ, Manavi K, Marson EJ, et al. Postgrad Med J. 2020;96:392-398.
Many COVID-19 patients present with respiratory symptoms, but others may present with atypical symptoms (e.g., delirium, smell and taste dysfunction, cardiovascular features). This article summarizes the evidence regarding these atypical presentations and the importance of physicians considering conditions which can “mimic” COVID-19 as part of the differential diagnoses in order to avoid diagnostic uncertainty and diagnostic errors.

Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.
The Associated Press. Flu shot mix-up at Oklahoma facility leaves 10 hospitalized. NBC News. November 8, 2019.
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This story highlights a failure that resulted in the misadministration of insulin during a flu vaccination program.
Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.
Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Cook H, Parson J, Brandt N. J Gerontol Nurs. 2019;45:5-10.
This medical record review study of patients admitted to long-term care following a hospitalization found that medication discrepancies were highly prevalent between the patients' home medication lists, hospital discharge summaries, the electronic health record, and the facility's initial physician order sheet. This work highlights the challenges of accurate medication reconciliation.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Schulte F; Lucas E; Mahr J.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.