Classics and Emerging Classics

Reducing opioid prescribing in pain management is a key strategy to address the opioid crisis. This review highlights the unique role of the anesthesiologist in this approach. The authors emphasize preoperative identification of patients at risk for long-term opioid use and suggest organizational, clinical, and research strategies that can be led by anesthesiologists to reduce opioid use.

Many older patients experience medication-related harm due to inappropriate prescribing. This meta-analysis found that potentially inappropriate medication prescribing in older patients worsened health-related quality of life and increased emergency department visits and hospitalizations. A WebM&M commentary discussed strategies for safer medication management for older patients.

Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.

Advanced computing holds promise for reducing missed diagnoses of cancer. This metanalysis found that computer-aided diagnosis effectively detects melanoma; however, studies were low in quality. The authors suggest that these systems may help assist dermatologists in overcoming the limitations of human cognition for performing repetitive tasks.

Simulation training can enhance teamwork, identify latent problems, and contribute to improved patient outcomes. This commentary explores the value of frontline obstetric simulation to develop high reliability. The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of a successful simulation-focused organizational learning initiative.

Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.

Disruptive and unprofessional behavior in health care can compromise safety culture. Prior research has shown that male physicians and those working in procedural specialties may be more likely to demonstrate unprofessional behavior. Experiencing such incivility may have important implications on the clinical performance of those impacted. In this multicenter, prospective, randomized controlled trial, researchers subjected anesthesiology residents to a simulated operating room emergency in either a normal or a disrespectful environment; blinded evaluators rated their performance. They found that residents exposed to rude environments scored lower on every performance measure, although there was minimal difference in the self-assessment scores between the two groups. The authors suggest that improving the culture in operating room environments is crucial and advocate for focused education on communication in stressful situations during medical training. A past WebM&M commentary discussed an incident involving a communication failure in a pediatric intensive care unit.

Reducing patient harm associated with the use of opioids to manage pain is a patient safety priority. This review discusses how to reduce risk of opioid misuse among three groups of patients: opioid-naive patients, patients on long-term opioid therapy, and those with a history of substance abuse. Strategies include disposal recommendations, tapering, and coprescribing of naloxone.

Machine learning may have the potential to improve clinical decision-making and diagnosis. In this study, machine-learning algorithms generally performed better than human experts in accurately diagnosing 7 types of pigmented skin lesions and the top 3 algorithms performed better than the 27 physicians.

Transitions of care represent a vulnerable time for patients. Older adults in particular may experience a variety of challenges related to such transitions, including managing changes to their medications. This systematic review suggests that there is significant opportunity for health care providers to improve family engagement in managing medications of elderly patients during care transitions.

High-risk opioid prescribing by providers contributes to opioid misuse. This systematic review sought to identify factors that confer risk for opioid addiction and thereby suggest which patients can safely take opioids. Researchers found that a prior history of substance use disorder, prescription of psychiatric medications, certain mental health diagnoses, higher daily opioid doses, and prescription of opioids for 30 days or more may confer risk for opioid addiction. The only factor associated with a lower risk of opioid use disorder was absence of a mood disorder. They could not identify any screening instruments or tools that accurately risk-stratified individuals' likelihood of opioid addiction. An Annual Perspective discussed problematic prescribing practices that likely contribute to adverse events and described promising practices to foster safer opioid use.

Drug shortages are a complex worldwide challenge to safe patient care. This review found economic, clinical, and psychosocial consequences associated with medication shortages for both patients and organizations. Highlighting weaknesses in the evidence base that stem from lack of data consistency, the authors describe the need for structured data on the medication shortage phenomenon to clarify their impact on patients across developed and developing countries. A WebM&M commentary explored medication safety in the context of drug shortages.

Mindfulness supports reliability, team performance, and resilience. This literature analysis assessed the evidence on how mindfulness affects patient safety, treatment outcomes, and patient-centered care. The review revealed moderate influences on the overall ability of clinicians to provide effective care, but the authors conclude that further research is needed.

The Beers criteria serve as standard guidance for clinicians to prevent potentially inappropriate prescribing in patients age 65 years and older. This update of the Beers criteria examined current evidence to determine changes required to keep the recommendations in step with current practice and knowledge. Nearly 70 modifications have been made to the 2015 set.

In this retrospective analysis of Medicaid claims, researchers found that opioid medications are often discontinued abruptly, presumably for safety reasons. Nearly half of patients who had opioids suddenly discontinued or with short tapering lengths experienced an opioid-related emergency department visit and hospitalization, suggesting an unintended consequence of reducing opioid use.

Nontechnical skills, such as teamwork and communication, are critical to safe care delivery, but can be difficult to measure. This systematic review examined validated approaches for assessing nontechnical skills using direct observation. Researchers analyzed 118 articles that discussed 76 unique tools for measuring nontechnical skills. This wide range of instruments assessed individuals or teams in various health care settings, either in simulation or actual clinical practice. They identified substantial variability in how these approaches were validated and whether individual studies reported the usability of each tool. The authors spotlight the need for standardization in how to develop, test, and implement assessments of nontechnical skills. A related editorial discusses the findings of this systematic review in the context of previous research and advocates for future work to standardize assessment of nontechnical skills in health care.

Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.

Researchers developed a deep learning algorithm to predict a patient's risk of lung cancer using information from current and prior CT scans. They found that the model performed better than six radiologists when prior imaging for the patient was available, with a reduction in both false positives and false negatives. The authors conclude that the use of such algorithms represents an opportunity to improve lung cancer screening processes.

This article provides an overview of racial and ethnic differences in the experience and management of pain, including pain-related coping, perceived bias and discrimination, patient preferences, expectations, patient-provider communication, differences in treatment outcomes, and access to healthcare.

Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.