Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.

Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.

Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.

Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.

Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.

This commentary discusses the harms of opioid overprescribing, particularly among opioid-naïve patients. The authors suggest that opioid dependence, abuse, or overdose in an opioid-naïve patient undergoing surgery should be considered a “never event” and discuss strategies for appropriate prescribing by surgeons.

In 2016, the Centers for Disease Control and Prevention (CDC) issued opioid prescribing guidelines that recommended limiting the duration of therapy for acute pain. Research has found that the guidelines have changed opioid prescribing in the emergency department, but less is known about the impact on postoperative opioid prescribing. This study examined the effect of opioid prescribing duration limits in Massachusetts and Connecticut on postoperative prescribing. Dosing duration limits resulted in decreases in postoperative prescription size and days supplied in Massachusetts but not in Connecticut.

Since 2013, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) has reduced payments to hospitals with elevated rates of specific outcomes deemed to be preventable sources of harm. To better understand the impact of the HACRP in Michigan, this study used a surgical registry to compare trends in rates of outcomes targeted by the program to concurrent trends for other hospital-acquired conditions, such as postoperative cardiac arrest and postoperative pneumonia. The authors saw an overall decrease in all hospital-acquired conditions over the eight-year study period but did not identify a statistically significant change in the rate of HACRP-targeted versus non-targeted conditions. The authors acknowledge that these findings may not be generalizable nationally because of robust quality improvement efforts already in place in Michigan, such as existence of other quality improvement efforts, such as the AHRQ-recognized Michigan Surgical Quality Collaborative and the Hospital Engagement Network

This retrospective cohort study found that adolescent patients who received opioids for surgical and dental procedures were more likely to develop persistent opioid use if they had family members with long-term opioid use. The study team recommends preoperative screening for long-term opioid use in family members as part of prescribing decision-making for adolescent patients.

Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.

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.

Various regulatory and policy initiatives are being implemented to encourage more responsible opioid prescribing in the face of the ongoing opioid epidemic. One such federal initiative, implemented by the Drug Enforcement Agency in 2014, was to change hydrocodone to a schedule II agent, which restricted hydrocodone to a 90-day supply that could not be prescribed or refilled by telephone. This study examined the effect of the change on hydrocodone prescribing for patients in Michigan who had undergone elective surgery, using a database that measured opioid prescriptions filled by patients. Implementation of the new regulation was associated with an unexpected increase in the amount of opioids filled initially after surgery. Although prescription refill rates decreased, overall there was no significant difference in the total amount of opioids prescribed within the 30-day postoperative period after the schedule change was implemented. The authors hypothesize that the increased restrictions on hydrocodone prescribing may have resulted in surgeons giving larger initial prescriptions in order to ensure postoperative pain control. The effect of national regulatory initiatives on opioid prescribing remains unclear at present, but recent studies have shown that personalized feedback to prescribers may be effective at improving prescribing.

Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.

This pre–post study examined the effect of implementing an evidence-based opioid prescribing guideline following cholecystectomy surgery. After guideline implementation, the average number of opioid pills per prescription declined, but no increase in refill requests occurred. More patients were prescribed nonopioid pain medications after guideline implementation than before. These promising results suggest a path toward reducing the use of these high-risk medications.

Prior studies demonstrate that disclosure of medical errors to patients is central to maintaining a therapeutic provider–patient relationship. However, little is known about physicians' beliefs regarding the disclosure of other clinicians' errors. Investigators interviewed 30 oncologists to understand their attitudes toward disclosure of medical errors occurring prior to the referral of a patient. Most believed that error disclosure did not benefit patients and disclosure practices varied significantly.

The opioid crisis is one of the nation's most pressing patient safety problems. Concern has been raised that overprescribing of opioids may be an unintended consequence of efforts to improve patient satisfaction. However, this Michigan study found no relationship between postoperative opioid prescribing and patient satisfaction scores, indicating that efforts to reduce opioid prescribing may not adversely affect patient satisfaction.

Opioid medication use represents a significant safety problem in the United States. Overprescribing by providers is one factor contributing to the widespread use of opioids. Reducing inappropriate prescribing may help improve patient safety. Using claims data for 36,177 patients, investigators sought to better characterize new and persistent opioid use after surgery, defined as filling an opioid prescription between 90 and 180 days postoperatively. Although there was no major difference in persistent opioid use between those who underwent minor surgical procedures and those who underwent major surgical procedures, results demonstrated that opioid use persisted in greater frequency after surgery among patients with behavioral, pain, and substance use disorders. A recent PSNet perspective discussed patient safety with regard to opioid medications.

In response to the 2011 duty hour regulations, many residency programs are shifting toward night-team systems where residents work defined night shifts rather than traditional overnight call. This study from a pediatrics residency program found that although residents worked fewer hours per day under the night-team system, they also slept less.

Do resident physicians contribute disproportionately to medical errors? The evidence is mixed, despite the longstanding concern about a purported increase in errors in July, when most new residents start their training. This study compared complication rates in breast reduction surgery between surgical residents and an attending physician, and found no evidence of increased complications in procedures performed primarily by residents with close attending supervision. However, poor supervision of residents has resulted in substandard care in other settings.

The investigators analyzed the relationship between surgeon age and operative risk and conclude that, in general, surgeon age was not an important risk factor for patient mortality.