Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl.

… diagnostic errors in this vulnerable patient population. … Pisciotta W, Arina P, Hofmaenner D, Singer M. Difficult diagnosis in the ICU: …

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.

Work conditions can impact clinician satisfaction and the quality and safety of the care they provide. This study sought to identify the combination of systems features (team dynamics, provider-perceived safety culture, patient care coordination) that positively impact work satisfaction in primary care practices. Results showed a strong culture of safety combined with more effective team dynamics were sufficient to lead to improved work satisfaction.

Tall Man lettering (TML) is a recommended strategy to reduce look-alike or sound-alike medication errors. This simulation study used eye tracking to investigate how of ‘tall man lettering’ impacts medication administration tasks. The researchers found that TML of prelabeled syringes led to a significant decrease in misidentified syringes and improved visual attention.

… and adverse events in the Emergency Department. … Alsabri M, Boudi Z, Lauque D, et al. Impact of teamwork and communication training …

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

High reliability is a goal throughout health care. This commentary describes how lessons from high reliability organizations can be applied to accountable care organizations to enhance quality, reduce costs, and support population health. The authors describe ways to engage organizations in this work through mindfulness, leadership, and research.

Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.

This qualitative study used data from free-text survey comments to examine the effectiveness of surgical safety checklist implementation at 11 hospitals. Although most operating room staff viewed the checklist positively, obtaining buy-in for consistent checklist use by all staff remained challenging.

Delayed diagnosis of colon cancer due to missed screening or follow-up leads to preventable morbidity and mortality. In this quality improvement effort, the study team sought to enhance colon cancer screening in primary care. They identified several important drivers of successful screening programs, including leadership support, patient engagement, teamwork, tracking of results, closed loops for referrals, and health information technology tools to support best practices. Sequential plan-do-study-act cycles were implemented to improve processes. Participating practices had widely varying baseline screening rates, and some sites demonstrated significant improvements from baseline while others did not change. The effort required to augment colon cancer screening in primary care demonstrates the challenge of implementing evidence-based practices in order to achieve timely diagnosis of cancer.

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

… sepsis  or septic shock. … Rhodes A, Evans LE, Alhazzani W, et al. Crit Care Med. 2017 Mar;45(3):486-552. doi: …