Classics and Emerging Classics

Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.

Deprescribing or stopping unnecessary medications is an important strategy for reducing medication-related harm in older adults. A group of 1981 Medicare beneficiaries reported broad support (92%) for stopping at least one of their medications if their clinician determined it was safe. A WebM&M commentary provides in-depth recommendations to achieve safe prescribing in older patients.

Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.

Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.

Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.

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.

This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.

This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.

Clinical decision support on the front line of care harbors both potential benefits and barriers to effective care delivery. This commentary outlines system challenges such as complexity and poor communication that hinder reliable adoption and use of clinical decision support. The authors highlight the need for research and evaluation models to help bring clinical decision support safely and effectively into daily health care work.

Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.

Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.

Cognitive biases can lead to unnecessary treatment and delays in diagnosis. This commentary reviews examples of bias that commonly occur in medical practice and describes debiasing tactics to help improve decision-making.

The release of the Institute of Medicine's To Err Is Human in 1999 represented a seminal moment in patient safety and is considered by many to have launched the modern patient safety movement. The report highlighted the incidence of medical errors and preventable deaths in the United States and catalyzed research to identify interventions for improvement. The authors reflect on progress since its publication and suggest that while many effective interventions have been developed for addressing safety challenges such as hospital-acquired infections and medication errors, successful implementation of these solutions remains difficult, and improvement in other areas has been less consistent. In addition, new safety challenges have emerged in the last 20 years including those related to ambulatory care and diagnostic error. The authors conclude that preventable harm remains significant and advocate for enhanced use of widely available electronic data to develop improved interventions for what they foresee may be a Golden Era of swift progress in patient safety. A PSNet perspective reflected on patient safety progress in surgery. The Moore Foundation provides free access to this article.

Use of artificial intelligence (AI) and computer algorithms as tools to improve diagnosis have both risks and benefits. This commentary explores challenges to implementing AI systems at the front line of care in a safe manner and identifies weaknesses of advanced computing systems that influence their reliability.

Physician burnout threatens the well-being and sustainability of the health care workforce. This large prospective cohort study found that 45% of resident physicians experienced burnout. Higher burnout rates were detected in urology, general surgery, emergency medicine, and neurology residents (relative to internal medicine residents). The overall prevalence of burnout was similar to studies of practicing physicians, and significantly higher than studies of the general population. Although most residents were satisfied with their career choice, those who were burned out were more likely to regret their decision to become a physician. An Annual Perspective explored how burnout impacts patient safety.

The opioid epidemic continues to be a pressing patient safety challenge in the United States. Many efforts have been implemented to curb opioid prescribing, such as policy initiatives and targeted feedback to individual clinicians. A major initiative was the release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for patients with chronic pain. These guidelines (which do not apply to patients with cancer or patients receiving palliative care) called for initially using nonopioid medications and nonpharmacologic approaches to chronic pain before using opioids, prescribing immediate-release instead of long-acting medications, and avoiding use of other sedating medications. This study examined trends in opioid prescribing rates before and after the CDC guidelines were released. Investigators found that opioid prescribing overall has decreased between 2012 and 2017, but the rate of decline increased after dissemination of the CDC guidelines. Perhaps the most notable finding is that the number of high-dose opioid prescriptions declined by nearly 50% over the study period (from 683 to 356 prescriptions per 100,000 adults). An Annual Perspective discussed the causes and potential solutions to opioid overprescribing.

The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.

The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.

Machine learning, a type of computing that uses data and statistical methods to enable computers to progressively enhance their prediction or task performance over time, has been widely promoted as a tool to improve health care safety. This commentary describes the potential for machine learning to worsen socioeconomic disparities in health care. Disadvantaged populations are more likely to receive care in multiple health systems. Therefore, relevant data about their health may be missing in an individual health system's records, hindering performance of machine learning algorithms. Racial and ethnic minority patients may not be present in sufficient numbers for accurate prediction. The authors raise concern that implicit bias in the care that disadvantaged populations receive may influence algorithms, which will amplify this bias. They recommend inclusion of sociodemographic characteristics into algorithms, building and testing algorithms in diverse health care systems, and conducting follow-up testing to ensure that machine learning does not perpetuate or exacerbate health care disparities.

Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.