An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

… has increased interest in using artificial intelligence (AI) to detect errors, including preventable adverse drug … promising areas where AI could be used to predict (e.g., therapeutic response) or detect (e.g., medication … prescribing errors) patient harm.  … Syrowatka A, Song W, Amato MG, et al. Key use cases for artificial intelligence to …

… testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the …

One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.

Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.

Clinical decision support (CDS) systems are intended to support diagnosis and therapeutic processes of care. This position paper defines adaptive CDS as “systems that can learn and change performance over time, incorporate new clinical evidence, data types, data sources, and methods for interpreting data.” Recommendations for the effective management and monitoring of adaptive CDS are outlined.

Quality measurement is increasingly being incorporated into policies outlining healthcare provider reimbursement. This study compared quality measure calculations between an individual electronic health record (EHR) source and the same EHR source combined with health information exchange (HIE) data. The results show that adding HIE data changed 15% of quality measure calculations. The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate and representative quality measurement.

… patient-specific and clinically appropriate.   … Shah SN, Amato MG, Garlo KG, et al. Renal medication-related clinical …

… errors in nursing home residents. … Kane- Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen …

Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  

… drug events occurred per 100 overrides.  … Edrees H, Amato MG, Wong A, Seger DL, Bates DW. High-priority drug-drug …

Medication errors occur frequently in the outpatient setting and can lead to patient harm. A common scenario is one in which a patient is prescribed multiple medications, does not know what each one is for, and takes them incorrectly. Medication safety experts have advocated that prescribers include indications on prescription labels to enable patients and pharmacists to check the bottle in order to remember a medication's purpose. Investigators examined more than 4 million outpatient prescriptions from a single institution and found that only 7.4% of prescriptions included an indication. Medications for symptoms like pain, nausea, and anxiety were much more likely to have indications than medications for chronic diseases. Internal medicine physicians, whose patients are more likely to take multiple medications, wrote indications 6% of the time. A PSNet perspective explored how community pharmacists can use medication indications and other tools to ameliorate medication-related harm.

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

… associated with computerized decision support. … Wright A; McEvoy DS; Aaron S; McCoy AB; Amato MG; Kim H; Ai A; Cimino JJ; Desai BR; El-Kareh R; Galanter W; Longhurst …

This simulation study compared computerized medication order entry between two commercial electronic health records and a prototype designed for safe prescribing. Physicians using the prototype had fewer errors compared to either commercial platform, highlighting the need to improve electronic health record usability in order to enhance medication safety.

This direct observation and interview study examined safety activities associated with electronic health records. The study team identified decision making, organizational learning, and frontline user engagement (including clinical decision support and training) as the three critical areas for safe use of electronic health records.

In this cluster-randomized trial, researchers examined the impact of an automated phone call with the option of transfer to a live pharmacist on detecting potential adverse drug events for patients newly started on medications for certain conditions in the primary care setting. Patients receiving the intervention were more likely to have medications stopped with documentation reflecting adverse effects.

Although clinical decision support is intended to improve safety, decision support alerts often result in alert fatigue and overrides. This prospective observational study examined overrides for exceeding the maximum dose of a medication in the intensive care unit. Researchers determined that insulin was the most frequent medication for which a maximum dosage alert was overridden. In almost 90% of cases, the overrides were deemed clinically appropriate. The authors conclude that more intelligent clinical decision support for medication dosing is needed to balance safety with alert fatigue in the intensive care unit. A past PSNet perspective discussed the challenges of implementing effective medication decision support systems.