… indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated …

Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

… intra-team communication and situational awareness . … Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in …

In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

Hospitals employ a variety of strategies to prevent inpatient falls. Based on data from incident reports, this study used process mapping to identify opportunities to improve timely diagnosis of serious injury resulting from inpatient falls. Researchers found that multiple interventions (e.g., education, changes in the transport process) with small individual effects resulted in a substantial cumulative positive impact on delays in the diagnosis of serious harm resulting from a fall.

When an error or adverse event occurs, patients and families want to be informed. In this study of oncology patients, more than one quarter perceived an adverse event had occurred. While most were informed soon after the event occurred and given an explanation, fewer than half were given information on how to move forward with a complaint if they wished. Regular communication between patients and providers about actual or perceived adverse events may decrease the risk of it happening again.

… hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). … currently available quality measures. … Field  TS, Fouayzi H, Crawford S, et al. The association of nursing home characteristics and …

Open disclosure of errors and adverse events is increasingly encouraged in health care. This survey of nurses working in oncology settings explored their perspectives about the accuracy of patient-reported errors, use of best-practice disclosure standards by health systems, and the influence of nursing experience on error disclosure. Strategies to overcome barriers should include systems-level approaches, such as regular audits and feedback of patient-reported errors.

Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  

This article evaluates the implementation of the We Want to Know program, which encourages hospitalized patients to speak up about breakdowns in care. Over a three-year period at one large, community hospital, the program interviewed over 4,600 patients and identified 822 (17.6%) who experienced a breakdown in care. Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at the hospital about it. Stakeholders (e.g., nurses, nurse managers, physicians, hospital administrators and leadership) found the program reports provided timely, actionable information and allowed for real-time responses and resolutions. Concerns cited by stakeholders included overlap with exiting patient safety reporting efforts, high level of effort and resources required, ensuring adequate responses.

Oncology patients, as with other patients with chronic health care needs, face numerous challenges during the COVID-19 pandemic. The authors discuss the need to balance delays in cancer diagnosis or treatment against the harm of COVID-19 exposure, how to mitigate the risk for significant care disruptions associated with social distancing and managing the allocation of limited healthcare resources during this unprecedented pandemic.

This study describes a multi-disciplinary quality improvement project aimed at increasing the percentage of completed medication reconciliations upon admission. Interventions included EHR workflow redesigns, provider training, and performance data reporting. After seven months, the project resulted in an increase in medication reconciliation at admission, and a higher percentage of medication reconciled across drug classes, including high-alert drugs.

Cancer patients have reported a desire to be informed of errors and to receive an apology from the provider. In this study of more than 1,100 adult medical oncology patients, 13% felt they had experienced an error, yet less than half received an apology or were told how the error would be prevented in the future. Organizational support and provider training on how to disclose errors may increase the percentage of patients receiving an apology.

Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

… not disclosing information. Disagreement with a clinician's recommendation or failure to understand a clinician's instructions were common. Patients most often did not …

Failure to speak up and raise concerns in the clinical environment can adversely impact patient safety. In this randomized controlled trial, simulation-based education provided to postpartum and labor and delivery nurses in the intervention arm was not associated with a difference in speaking-up scores as compared to those in the control group overall.

Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.