Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.

Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.

… a similar illness within two weeks. … Neprash HT, Sheridan B, Jena AB, et al. Evidence of respiratory infection …

Adolescent patients transitioning from pediatric to adult medicine may experience patient safety risks. Using a large commercial insurance claims database, the authors compared opioid prescribing patterns and risk for opioid-related adverse events (overdose, opioid use disorder, or long-term use) among adolescents transitioning from “child” to “adult” at 18 years of age. The authors estimate a 14% increased risk for an opioid-related adverse outcome within one year when “adults” just over age 18 years were prescribed opioids that would not have been prescribed if they were under 18 years and considered “children.” The authors discuss how systematic differences in how pediatric and adult patients may be treated can lead to differences in opioid prescribing.

In 2003, the Accreditation Council for Graduate Medical Education limited resident physician work hours to 30 hours in 1 shift and 80 hours in 1 week. These duty hour reforms were intended to enhance patient safety and trainee physician well-being. However, some have expressed concern that physicians who train for fewer hours will leave residency less skilled and ultimately provide lower quality care. Investigators assessed whether attending internists who trained with duty hour restrictions differed after residency in terms of their Medicare patients' mortality, readmissions, or costs when compared with internists who trained with unlimited duty hours. They found no difference in quality or cost between the two physician groups. Although other studies have concluded that duty hours have not adversely affected clinical or safety outcomes in residency, this study extends that finding to physicians' subsequent practice. Duty hour restrictions have consistently been associated with improved resident physician well-being. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.

This study used Medicare data to examine the relationship between potential opioid misuse and opioid overdose. Researchers defined six possible indicators of opioid misuse (e.g., obtaining opioids from more than five prescribers or more than five pharmacies) in a manner conceptually similar to trigger tools. Patients with any of these opioid use triggers were significantly more likely to experience an overdose within the next 6 months. These results provide insight on how best to use data from prescription drug monitoring programs, which are now widely used as a tool in combating the opioid epidemic.

This study examined whether receiving care from locum tenens (short-term substitute) physicians in hospital internal medicine practice affects patient outcomes. The concern is that discontinuity might increase risk for adverse events. This retrospective observational cohort study of Medicare patients found no differences in 30-day mortality in those treated by locum tenens physicians compared to those who were not exposed to any substitute physicians. While costs and length of stay were higher for patients with substitute physicians, readmission rates were lower. The authors conclude that locum tenens physicians do not adversely affect safety outcomes like mortality.

Policy solutions are one approach to help change prescribing and use patterns that have contributed to the opioid epidemic. This commentary describes how a state-level program sought to reduce opioid misuse and highlights the need for effective monitoring to drive policy-focused improvement initiatives.

This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.

… his role in the organization. … Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation …

The opioid epidemic is currently one of the most pressing patient safety challenges, as discussed in a recent Annual Perspective. High-risk prescribing practices by clinicians is one contributing factor in the surge in opioid use among patients. Prior research has shown that patients often receive opioids following low-risk procedures, and they frequently receive opioid prescriptions even after overdosing on these medications. This cohort study found wide variations in opioid prescribing practices among emergency departments, with some physicians prescribing opioids almost three times as often even after controlling for patient characteristics. Notably, patients who received opioids from a high-intensity prescriber were significantly more likely to continue using opioids 12 months later—indicating a possible connection between physician prescribing practices and subsequent opioid addiction. The study confirms that reducing variation in physician prescribing practices should be one component of an overall strategy to address opioid overuse.

The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.

Misuse of prescription opioids represents a serious patient safety issue. In this study, investigators examined opioid prescribing to Medicare beneficiaries upon hospital discharge. They found that new opioid use was common after discharge and that prescribing rates varied widely across hospitals.

Electronic health records (EHRs) offer safety benefits, but the disruption associated with EHR implementation can lead to unintended consequences as well. This observational study sought to determine whether the incidence of adverse patient outcomes (including certain AHRQ Patient Safety Indicators, readmissions, and mortality) was higher at 17 hospitals that were transitioning to a new EHR than in 399 hospitals that did not change their EHR. Investigators found no significant difference between safety outcomes of hospitals with a new EHR and those without a new EHR. This large-scale study across multiple institutions demonstrates that patients' care remains safe during EHR transitions. The authors suggest that these results should allay safety concerns for institutions planning to implement EHRs. A PSNet interview described the challenges associated with EHR transitions.

This commentary describes misprognosis as enacting inappropriate intervention for a correct diagnosis. In light of the current emphasis on diagnostic error, the authors emphasize the need for clinicians to consider patient physical and social contexts when selecting interventions after diagnosis. They call for research to explore how education, measurement, and system can be improved to reduce prognostic errors.

Defensive medicine—the practice of performing potentially unnecessary procedures or diagnostic tests to avoid the threat of malpractice liability—is thought to contribute to high health care costs in the United States. Because procedures and tests carry risks of complications, defensive medicine also may lead to adverse events. This secondary data analysis examined prospectively whether physicians who performed more cesarean deliveries (considered to be defensively motivated) were more or less likely to be subject to malpractice claims compared with those performing fewer cesarean deliveries. Researchers adjusted for available clinical characteristics and still found that obstetricians who performed more cesarean deliveries were less likely to have subsequent alleged malpractice incidents. This finding suggests that defensive medicine may be a rational physician response to the current malpractice environment, and underscores the patient safety rationale for malpractice reform. A previous WebM&M commentary discusses the causes and consequences of defensive medicine.

… health and economic implications. … Khullar D, Jha AK, Jena AB. Reducing Diagnostic Errors--Why Now?.  N Engl J Med …

This study examined adverse drug events reported to the FDA by manufacturers. Less than 10% of reports were delayed beyond the 15-day reporting requirement, but adverse events involving death were more likely to be delayed. This finding suggests that current regulatory policy could be optimized to promote timely reporting in all cases.

The 2003 regulations that limited resident duty hours substantially altered graduate medical education. Although the reductions were implemented with the stated goal of improving patient safety, clinical outcomes remain largely unchanged. A potential unintended consequence of decreased duty-hours is decline in educational quality leading to lack of preparedness for independent practice. To examine physician performance after training, this study compared senior physicians (with 10 or more years of post-residency experience) to new physicians (with no more than 1 year of experience) who had reduced duty-hours during training. The authors found no difference in terms of their patients' length of stay or hospital mortality. These results show that the 2003 regulations did not worsen patient outcomes, but they do not address the more sweeping 2011 duty hours reforms prompted by the 2008 Institute of Medicine work hours report.