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.

Clinician skills can decrease with age. This retrospective analysis of 1.9 million preliminary interpretations of radiology imaging findings examined the relationship between radiologist age and diagnostic errors. While the overall mean error rate for all radiologists was low (0.5%), increasing age was associated with increased relative risk of diagnostic errors.

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.

… J Physician Assist Educ … A study conducted in 2011 concluded …

Occupational fatigue (e.g., stress, physical fatigue) can have deleterious effects on patients, staff, and health systems. This article describes a conceptual framework to better understand the factors contributing to occupational fatigue and downstream implications (e.g., poor patient safety, employee burnout, lower retention, and higher turnover).

Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Radiologic diagnostic errors can result in delayed or unnecessary treatment. This paper describes five types of cognitive biases, with accompanying case study and images, that result in misdiagnosis. Both individual education and system-level solutions are described.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

Racial bias negatively impacts maternal safety across all stages of pregnancy. This study used two clinical scenarios to assess obstetricians' likelihood to recommend cesarean section during labor at three decision points. All participants received the same scenarios with the only difference being the patient's race (i.e., Black or white). No significant racial biases were detected overall, but one subgroup (younger providers and those with less experience) opted for cesarean delivery more frequently for Black patients than white patients at one decision point.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

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.

Missed nursing care is a key indicator of patient safety and has been linked to safety climate. Survey responses from 3,429 labor and delivery nurses from 253 hospitals across the United States found an average of 11 of 25 aspects of essential nursing care were occasionally, frequently, or always missed. Higher perceived safety climate was associated with less missed care. The authors discuss the importance of strategies to reduce missed care, such as adequate nurse staffing, ensuring nonpunitive responses to errors, and promoting open communication.

Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

… or chronic health conditions. … Morris RL, Giles S, Campbell S. Involving patients and carers in patient safety …

The rapid expansion of digital health technologies, particularly in response to the COVID-19 pandemic, can increase patient safety risks. This article summarizes malpractice liability risks associated with digital health technologies, including electronic health record (EHR) systems, telehealth, and artificial intelligence for clinical decision support.

Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.

The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.