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.

Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.

Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.

This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

… across the VA system. … Elwy AR, Maguire EM, McCullough M, et al. From implementation to sustainment: a large-scale …

Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.  

… and the use of metrics to track CRP functioning.  … Gallagher TH, Boothman RC, Schweitzer L, et al. Making …

… prevent traditional legal actions. … Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try …

This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.

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.

This study held focus groups with breast cancer providers to better understand attitudes and experiences regarding communicating with patients about diagnostic errors. Researchers presented three hypothetical vignettes for discussion. Participants identified challenges related specifically to breast cancer as well as challenges stemming from team-based care. To improve communication about these errors, participants recommended educating patients, being honest and empathetic, and focus on the positive and the patient’s future.

This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.

… needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that …

Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.