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Isaksson S, Schwarz A, Rusner M, et al. J Patient Saf. 2022;18:325-330.
Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations. 
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.
A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.
Beed M, Hussain S, Woodier N, et al. J Patient Saf. 2022;18:e652-e657.
Critical incident reporting is an important method to detect patient safety hazards and improve care. A research team in one large UK tertiary hospital reviewed cardiac arrest calls and cardiopulmonary resuscitation (CPR) events reported to the hospital incident reporting system; ten thematic areas for potential improvement were identified (e.g., failure to rescue, staffing concerns, equipment/drug concerns). Organizations could replicate this longitudinal process to improve high-risk patient safety event outcomes.
Cucchiaro SÉ, Princen F, Goreux JË, et al. Int J Qual Health Care. 2022;34:mzac014.
Patient satisfaction surveys, unexpected event reports and patient complaints can each be used to improve patient safety. This radiotherapy service combined the three sources to make improvements in safety and quality. Results highlighted areas of strength (e.g., physical healing, kindness) and areas to improve (e.g., scheduling, comfort). Involving the patient in this way could lead to improvements in quality and safety.
Reijmerink IM, Bos K, Leistikow IP, et al. Br J Surg. 2022;Epub Apr 4.
Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 
Iedema R. BMJ Qual Saf. 2022;31:234-237.
Patients and families impacted by preventable adverse events frequently share their stories when advocating for safety improvements. The author of this commentary urges healthcare, patient safety, and quality improvement professionals to listen to patient safety stories, not just as technical information, but as behavioral challenges.

Health Service Journal. September 15-16, 2022. Manchester Central Convention Complex, Manchester UK.

Patient safety is challenged worldwide due to the daily complexity of care. This session will focus on never events. Areas of specific exploration will include what factors in the environment enable never events, the value of proactive assessment of practice to prevent never events, and the viability of never event classification schemes. 
Zerah L, Henrard S, Thevelin S, et al. Age Ageing. 2022;51:afab196.
Adverse drug events (ADEs) are an important cause of hospitalizations in older adults. Based on data from the OPERAM trial, this study explored the accuracy of triggers for identifying medication-related hospital admissions in older adults. Triggers were related to diagnoses (e.g., falls, bleeding, thromboembolic events), laboratory values (e.g., hypo- or hyperglycemia) and other factors (e.g., mention of an ADE in the patient record, abrupt medication discontinuation). Among 1,235 included hospitalizations, 58% cases had at least one trigger; medication-related admissions were adjudicated in 72% of these cases.
Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Eiding H, Røise O, Kongsgaard UE. J Patient Saf. 2022;18:e315-e319.
Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.
Höcherl A, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18:e85-e91.
Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.