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.

The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.

Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.  

Mandatory error reporting systems can help identify types, causes, and solutions to medication-related errors. More than 30,000 medication-related incidents were reported by community pharmacists to the Assurance and Improvement in Medication (AIMS) Program in Canada. Event type, severity, medication class, and method of detection are described. Only 60% of pharmacies submitted at least one report, indicating compliance with and participation in the AIMS Program remains low.

Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.

Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.

Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Leadership engagement in safety is essential to implementing sustainable change. This qualitative study found that rational persuasion and legitimating were the most frequently used and certain factors – such as organizational culture, safety beliefs, and leadership style – can impact how safety professionals influence managers making safety decisions in healthcare settings. The authors discuss the importance of both technical and non-technical skills to enhance influence among safety professionals.

The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.

Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.

Simulation training is often used to develop clinical and nontechnical skills as part of nursing education.  This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.

Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.

Research into patient safety culture in primary dental care remains limited. This commentary provides an overview of patient safety in dentistry and tools to develop a robust patient safety culture, including human factors and supporting second victims.

Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes. This commentary lays out the benefits of safety culture and how it can be implemented organization-wide, with a particular focus on mental health organizations. Specific interventions are discussed, including family involvement, leadership communication, and simulation.

Alteplase and other thrombolytics are high-alert medications. This study compared error rates of alteplase administration in patients presenting with acute ischemic stroke at either a regional hospital or a Comprehensive Stroke Center (CSC) and found that community hospitals had over a 10 times greater number of errors leading to hemorrhage. The study recommend to put safeguards in place to decrease the risk of alteplase medication administration errors.

… racism has been challenged by mass social movements. … Bailey  ZD, Feldman JM, Bassett MT. How structural racism …

In response to the COVID-19 pandemic, nursing homes limited access to visitors and family caregivers in order to limit virus transmission. Based on existing nursing home visitor policies, the authors developed data-driven, expert-reviewed guidance for re-opening Canadian nursing homes to family caregivers and visitors.

This study examined the prevalence and risk factors for COVID-19 infection among frontline healthcare personnel who work with COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between April 3 and June 19, 2020.  Six percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that they had been previously infected. This study highlights the role that asymptomatic COVID-19 infections play and authors suggest that enhanced screening and universal use of face coverings in hospitals are two strategies to reduce COVID-19 transmissions in healthcare settings.