In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.

In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Patient and caregiver engagement is an important strategy for improving the quality and safety of care. This qualitative study with 18 patients and/or caregivers explored perspectives on engagement in primary care. While participants were supportive of engagement in their care and safety, some expressed concerns regarding additional workload for patients. Participants also provided feedback on a patient safety guide for primary care (PSG-PC) and identified areas to embed the PSG-PC into routine interactions with primary care, particularly for individuals caring for a family member with complex or chronic health conditions.

Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.

Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 

Voluntary error reporting remains underutilized in many clinical settings despite its importance for organizational learning and improved patient safety. This pediatric health system implemented a new safety event management system (SEMS) aimed at increased usability, de-centralized event follow-up, and closed-loop communication. The new SEMS resulted in more event reporting and less staff time spent on each report.

… negative effects on patient safety. … Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork …

… J Health Serv Res Policy … A key aspect of patient safety … incident is considered a voiceable concern. … Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable concern in …

… capacity, and task-specific issues. … Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ …

… Intern Med J … Sound critical thinking skills can help clinicians avoid … during clinician training. … Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272 …

Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

… and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and formal … study. Soc Sci Med. 2021;280:114050. doi: 10.1016/j.socscimed.2021.114050. …

… Am J Health Syst Pharm … When patients are admitted to the … were of low risk of harm.   … Cicci CD, Fudzie SS, Campbell-Bright S, et al. Accuracy and safety of medication … of delirious or mechanically ventilated patients. Am J Health Syst Pharm. …

… Am J Health-Syst Pharm … Health systems have needed to rapidly … of responsibilities among pharmacy leadership (e.g., who monitors PPE inventory, medication distribution, … to a “black swan” event: the COVID-19 pandemic. Am J Health-Syst Pharmacy. 2021;78(7):552-555. …

… J Nurs Scholarsh … Using electronic health records, call … should be tailored to individual nurse risk factors. … Campbell AA, Harlan T, Campbell M, et al. Nurse's Achilles Heel: using big data to determine …

Medication errors represent a significant source of preventable harm. This large meta-analysis, including 81 studies, found that approximately 1 in 30 patients is exposed to preventable medication harm, and more than one-quarter of this harm is considered severe or life-threatening. Preventable medication harm occurred most frequently during medication prescribing and monitoring. The highest rates of preventable medication harm were seen in elderly patient care settings, intensive care, highly specialized or surgical care, and emergency medicine.

Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.