Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

Illegible prescriptions can cause pharmacists to dispense incorrect medications resulting in patient harm. This review identified 15 studies on illegible prescriptions. Most of the studies were more than 10 years old and the authors acknowledge the advent of computerized provider order entry (CPOE) has reduced incidence of illegible prescriptions. However, CPOE relies on highly functional information technology systems which may be cost-prohibitive for some countries.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.

Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.

Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

Medication errors at hospital discharge are a common cause of medication errors and adverse drug events (ADE). This review compared three types of discharge medication reconciliation: paper-based, electronic, and enhanced. Results suggest electronic medication reconciliation reduced the odds of a medication discrepancy or ADE, as compared to paper-based. Results were mixed on enhanced medication reconciliation.

Rapid response teams (RRT) are intended to improve the identification and management of clinically worsening hospitalized patients. This study identified an increase in RRT activations for respiratory distress at one academic hospital during the COVID-19 pandemic. The authors outline the hospital response, which included revising RRT guidelines to reduce in-room personnel, new decision-support pathways, which accounted for COVID-19 uncertainty, and expanded critical care consults for inpatient care team.

Health systems are rapidly adjusting and adapting processes to successfully respond to the COVID-19 pandemic. The University of Pennsylvania Health System developed the I-READI (integration, root cause analysis, evidence review, adaptation, dissemination, and implementation) conceptual framework to assist hospitals in preparing for and responding to patient safety challenges during times of crisis, such as the COVID-19 pandemic. The I-READI approach can streamline communication, enrich collaboration, and coordinate rapid change through the use of daily safety huddles, root cause analysis, and technology (e.g., ICU telemedicine and real-time ICU dashboards).

… a safe patient care environment … Forbes TH 3rd, Wynn J, Anderson T, et al. Understanding the peer, manager, and …

… components lead to greater improvements.   … Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability …