Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  

… for medical product shortage. … Miller  FA, Young SB, Dobrow M, et al. Vulnerability of the medical product supply chain: …

… Sutherland JJ; Morrison RD; McNaughton CD; Daly TM; Milne SB; Daniels JS; Ryan TP. …

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Opioids are known to be high-risk medications, and unsafe prescribing practices are common. This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback to clinicians about high-risk opioid prescribing. Local champions implemented the dashboard tool and spearheaded safer opioid prescribing. Using an interrupted time series analysis, researchers determined that the intervention reduced two unsafe prescribing practices: high-dose opioid prescriptions and concurrent use of opioids and benzodiazepines. The authors suggest that this type of large-scale intervention could be applied in other health care systems to enhance opioid safety. A recent Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to foster safer opioid use.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

This review explored the relationship between providers, health disparities and pain. Existing research has focused on how patient-provider interactions influence patient outcomes, satisfaction, adherence, and disparities. The authors note that future research should investigate how the interpersonal, therapeutic relationship between nurses and patients contribute to nursing care decisions and the provision of culturally competent care.

Delayed diagnosis from false-negative Papanicolaou (Pap) tests can have tragic results. This study re-screened liquid-based Pap tests of women who were later diagnosed with endometrial carcinoma. Of the 27 rescreened samples, 16 were recategorized to positive. Through root cause analysis, latent and active failures were identified, and several quality improvement initiatives were implemented.