Letter From the Editor

Abstract

This week marks Patient Safety Awareness Week. In this issue, you will find stories of the individuals and teams recognized by the Patient Safety Authority (PSA) in our 2022 I AM Patient Safety Annual Achievement Awards. The campaign was designed more than a decade ago to recognize advancements, outcomes, and commitment to patient safety. This year’s highlights include reducing central line–associated blood stream infections (CLABSI), reducing resident falls in a long-term care facility, implementing measures to reduce the risk of wrong-site surgeries, and many others. This issue’s cover features an article by Akiyama et al., who share a pilot study in a Japanese hospital to improve event reporting among physicians. Some of the barriers described mimic those we hear about from Pennsylvania providers: culture, fear, time constraints. They are all contributing factors of low reporting. The authors conclude that their intervention increased reporting among not only physicians, but also nonphysicians. Robert Yonash, patient safety liaison at the PSA, reminds us that the risk of experiencing a wrong-site surgery is still all too real. He explains why these events continue to occur and offers strategies for prevention. On March 19, 2022, PSA will release formal recommendations to ensure correct-site surgery and nerve blocks to Pennsylvania healthcare facilities. The recommendations will enhance existing guidance and add critical elements to further reduce this risk. Lea Anne Gardner, patient safety analyst, and Rebecca Jones, director of Data Science and Research at PSA, analyzed reports from the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to tracheostomies and laryngectomies. They teamed up with Christopher Rassekh, professor of Clinical Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania, and Joshua Atkins, associate professor of Anesthesiology and Critical Care and director of Anesthesia for Head and Neck Surgery at the Perelman School of Medicine at the University of Pennsylvania, to review their findings and identify potential safety strategies to reduce risk. Caitlyn Allen, managing editor at Patient Safety, sat down with representatives from Jefferson University to talk about their Health Mentors Program (HMP). HMP pairs students in clinical programs with persons in the community who are experiencing chronic conditions or disabilities and serve as their health mentors. HMP helps bridge the gap between clinical knowledge and understanding what it’s like to experience a health condition—a key component of patient-centered care. Other topics included in this issue are returns to surgery after tonsillectomies and adenoidectomies, medication safety in the emergency department, multidisciplinary initiatives to improve tracheostomy care, and advice on how you can write about your quality improvement initiatives for publication. This journal was designed for our authors to freely share the important work they do to improve patient safety, and for our readers to freely receive the information, strategies, and lessons learned to make the care they provide and receive safer. Thank you to our authors, reviewers, staff, editorial board, and readers for your continued contributions. Stay safe and stay well!