Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

… Programme Grants Appl Res … Electronic prescribing … organizations in e-prescribing system decision making. … Sheikh A, Coleman J, Chuter A, et al.  Programme Grants Appl Res.  2022;10(7): 1-196.  …

Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.

… optimizing existing information technology, enhanced team communication and coordination, and greater continuity …

Methadone and buprenorphine are commonly prescribed to treat opioid use disorder, but their use presents patient safety risks. Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care stemmed from errors in dispensing practices (e.g. wrong patient, incorrect dose, incorrect formulation). Staff- and organization-related factors – such as not following protocols, poor continuity of care – contributed to more than half of the incidents.

Most patient safety research has focused on tertiary care or specialty care settings, but less is known about safety in primary care settings and there is no clear definition of patient safety incidents and harm occurring in these settings.  The authors convened a panel of family physicians and used a consensus method to define “avoidable harm” within family practice. Most scenarios found to be avoidable and included in the proposed definition involved failure to adhere to evidence-based practice guidelines, lack of timely intervention, or failure in administrative processes, such as referrals or procedures for following up on results.

Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.

The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.

When patients and caregivers report adverse events, they may identify unique issues that other reporting systems do not capture. The authors propose adjustments to AHRQ's Common Formats for safety event reporting that allow patients and caregivers to more effectively report adverse events. An Annual Perspective emphasized the value of patient adverse event reporting in larger efforts to engage patients in their safety.

Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.

Improving patient safety in the ambulatory setting is an increasing area of focus. In this study, investigators described the use of a patient safety toolkit across 46 outpatient family practices in England.

Although computerized provider order entry (CPOE) reliably reduces medication errors, clinical decision support has more varied impact on safety outcomes. System complexity, insufficient emphasis on human factors engineering, and alert fatigue limit utility of clinical decision support. This study rigorously examined medication error rates before and after implementation of CPOE with clinical decision support at three hospitals in England. In a sample of 2422 patients, the overall error rate decreased 20%. At one hospital, the error rate did not change because an increase in a specific insulin prescribing error counterbalanced all other error reduction. All three hospitals implemented clinical decision support, but the type, nature, and efficacy varied markedly, even between the two systems implementing the same CPOE. A PSNet perspective synthesized lessons for assessing electronic health record safety as a whole.

Computerized provider order entry and clinical decision support are patient safety strategies with significant implementation challenges. This qualitative study aimed to characterize engagement with these two activities across multiple hospitals in the United Kingdom. Investigators conducted interviews, employed direct observation, and reviewed documents such as implementation plans. Their analysis demonstrated a need for ongoing platform improvement (including bug fixes and local tailoring) and for monitoring how these two strategies are used to provide feedback and ensure optimal use. They conclude that in order to realize the benefits of computerized provider order entry and clinical decision support, hospitals must work with frontline staff over time, not just prior to implementation. In a previous PSNet interview, Dr. Robert Wachter discussed the challenges of implementing health information technology.

This systematic review examined physician-level and organizational-level interventions to improve outpatient medication safety. Existing interventions such as clinical decision support to identify high-risk patients, pharmacist medication review, and educational interventions for prescribers did not prevent medication-related emergency department visits, hospitalizations, or deaths. These results highlight the challenge of reducing serious adverse drug events in outpatient care.

Poor safety culture has been identified as a barrier to incident reporting. Researchers analyzed a sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System and found that blame was attributed to an individual in almost half of the reports. The authors suggest that successfully using incident reports to improve safety requires a shift to blame-free culture.

According to this mixed-methods analysis of 8 years of data, the most common voluntarily reported incidents involving older primary care patients in England and Wales were related to medication errors and inadequate communication between providers. Many of these errors occurred during the transition home after hospital discharge. These data provide targets for further research to develop methods for improving safety in ambulatory care.

Although computerized provider order entry is known to reduce medication errors, previous research has demonstrated that electronic prescribing can introduce new medication safety risks. This observational qualitative study of electronic prescribing at six British hospitals included direct observation, interviews, and analysis of implementation documents. Investigators determined multiple unintended consequences of electronic prescribing, at every stage of use, and identified design flaws in electronic prescribing platforms. Suboptimal implementation of electronic prescribing, with partial functionality and insufficient training, increased risk of errors. Once electronic prescribing was in place, prescribers started using workarounds and relied too much on the prescribing platform. The authors call for design and organizational strategies to mitigate these safety concerns. A past WebM&M commentary described a medication error related to electronic prescribing.

Since the inception of the patient safety movement, most research has focused on the inpatient setting. Although the focus on ambulatory safety has grown in recent years, little is known about adverse events in outpatient pediatric care. In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care patients from the England and Wales' National Reporting and Learning System over a 9-year period. Using descriptive and thematic analysis, researchers sought to identify the most common and serious event types, reasons these events occurred, and opportunities for improving safety. They found that about one third of 2191 safety incidents represented cases of severe harm. Based on their analysis, the authors conclude that efforts should focus on building safer systems for medication dispensing in community pharmacies, enhancing the triage process for sick children, and improving communication between providers and parents. An accompanying editorial discusses the value of incident reports with regard to improving care for pediatric primary care patients.

… improvement strategy. … Carson-Stevens A, Hibbert P, Williams H, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016. …