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St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

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.
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

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.
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.
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.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
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.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.
Lampert A, Haefeli WE, Seidling HM. J Patient Saf. 2020;16.
Through focus groups with patients, family caregivers and nurses, this study explored experiences with medication administration and perceived needs for assistance. Patients and caregivers were generally unaware of errors and primarily attributed administration problems to dosage form (eg, lack of confidence in using syringes). Participants identified lack of training or education about proper administration as contributing to administration errors.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
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.
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20:481-490.
The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.