This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.

Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.

… as measuring the impact of residency training programs. In a past PSNet interview , Dr. Tejal Gandhi, president of the … Leape Institute, discussed improving patient safety at a national level. …

The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.

… safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the … opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors …

… study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities …

… preventing overuse . In this study, researchers developed a validated High-Value Care Culture Survey and found that …

Patient safety research and commentary often focus on specialized care processes rather than medical wards. Exploring challenges to improving safety in the medical ward environment, this commentary outlines four strategies to address complexity of implementing initiatives in this setting.

Although financial incentives have been widely adopted, they may not lead to organizational improvements. This commentary raises concerns about including hospital mortality in incentive programs, since patient deaths do not necessarily mean poor quality care. The authors suggest that further research is needed to enhance accuracy of risk-adjusted mortality and to account for differences in patient treatment preferences.

Implementing standardized handoff processes has garnered attention as a strategy to improve patient safety. In this commentary, the authors apply cognitive load theory to handoff tasks to demonstrate how to improve handover bundles and enhance reliability.

… are increasingly common on medical wards, based partly on a widespread belief that these practices will improve … metrics to evaluate an intervention, which can undermine a program's mission. …

… residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into …

… Group , and Consumer Reports . Each rating system has a different emphasis, varying inclusion and exclusion … high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these … to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President …

This narrative review of safety efforts on general hospital wards found that most interventions encompass one or more of five areas: staffing levels, interprofessional collaboration, standardization of care such as use of checklists, rapid response to clinical deterioration, and safety culture. The authors advocate for increasing the evidence base in all of these areas, as gaps in implementation and sustainment are prevalent.

Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.