Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.

… coengineer safer health care systems. … Liu JJ, Rotteau L, Bell CM, Shojania KG. Putting out fires: a qualitative study …

Prior work has demonstrated that surgical outcomes differ depending on individual practitioner skill, and concerns have been raised regarding the need to assess skills of aging physicians. This study examined whether cataract surgery outcomes differ for late-career ophthalmologists, defined as those who completed medical school at least 25 years ago, compared to mid-career ophthalmologists, who completed medical school 15 to 25 years ago. This secondary data analysis of all single-eye cataract surgeries performed in Ontario between 2009 and 2013 found that almost 30% of procedures were performed by late-career practitioners. Overall, adverse surgical events did not differ by career stage, although very small increases in risk of two specific complications—dropped lens fragment and endophthalmitis, a surgical site infection—were observed. These results suggest that cataract surgery by late-career ophthalmologists does not pose a high-priority safety hazard.

… overdose as a patient safety problem. … Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of …

Regulatory agencies rely on physician reports of adverse events associated with medical devices in order to identify safety concerns. This qualitative interview study found that most physicians who implant devices do not regularly report adverse events related to particular devices. The authors recommend that postmarketing surveillance of medical devices be redesigned to foster detection of adverse events.

Conflict of interest between health care providers and for-profit industry represents a patient safety concern. This qualitative study examined the relationship between physicians who use implantable devices and the device manufacturer representatives. Although physicians reported being vigilant in their relationship with device representatives and recognized the potential for conflicts of interest, device representatives were often present for implantations.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Inappropriate antibiotic use contributes to microbial resistance for the recipient and the community. This study found increased harms related to antibiotic use among older patients living in nursing homes with higher antibiotic use compared to nursing homes with overall lower antibiotic use. These findings demonstrate the need to manage antibiotics effectively to improve the safety of all nursing home residents.

This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.

Preventing hospital readmissions has been a major health system priority for several years. Although recent data indicates that readmissions in adult patients are decreasing slightly, the approaches individual hospitals or health systems should use to prevent readmissions remain unclear. This randomized controlled trial evaluated the effect of a postdischarge virtual ward where patients received postdischarge care from a multidisciplinary team that met daily to review the patient's progress, conduct home visits, arrange home services, and coordinate care with the patient's primary physicians. Patients were admitted to the virtual ward for a mean of 35 days after discharge and received 3 home visits on average during that time. Despite the intensity of the intervention, there was no effect on 30-day readmissions or any other clinical outcome compared to usual postdischarge care. Another recent randomized trial found that a similarly intensive intervention did not reduce readmissions in a vulnerable elderly patient population. The authors of this study note that difficulty in communicating with primary care physicians, exacerbated by the lack of an integrated electronic medical record, may have contributed to the failure of the virtual ward at preventing readmissions.

This qualitative study identified key elements of successful local safety interventions. One prominent strategy was stakeholder ownership of a patient safety issue in a supportive interprofessional learning community.

An organization-wide patient safety program consisting of open access online educational modules, an online forum for communication, and a reward system, led to a significant increase in voluntary patient safety event reporting. The largest uptick was seen in near miss reporting, which nearly doubled following the intervention.

The hospital discharge process is often disorganized and lacks standardization. As a result, adverse events after hospital discharge are disturbingly common. This study reports on a multidisciplinary, collaborative effort—involving hospitalists, primary care physicians, home care and bedside nurses, and pharmacists—to develop a standardized hospital discharge checklist. The resulting tool is designed to be used daily during hospitalization as part of interprofessional discharge planning rounds and consists of seven domains that address key aspects of the hospital-to-home transition, including medication reconciliation and communication between physicians. Further validation will be required to demonstrate that this checklist can prevent adverse events in broad hospitalized patient populations.

This study identified three different scenarios associated with organizational responses to near misses.

While a growing number of descriptions of quality and safety teams have been published, this review found that the existing literature base has serious methodological flaws.

This study revealed that nurses perceived their role in team-based error disclosure as secondary to balancing professional boundaries.

… medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and …

This mixed-methods study characterized the types of interruptions that occur in nurses' daily workflow on medical and surgical units. Most interruptions were by other members of the care team, particularly on medical units.