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.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

Rates of prescription opioid misuse and abuse led to recommendations for dose tapering for patients with chronic pain. However, concerns have been raised about the potential harms associated with rapidly decreasing doses or discontinuing opioids. Building on previous research, these researchers used a large claims database to explore the unintended negative consequences of tapering patients on stable, long-term opioid therapy. Findings indicate that opioid tapering was associated with fewer primary care visits, greater numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications.

Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.

Reporting adverse events and lessons learned can help improve patient safety beyond the original impacted facility, but low-quality reports can hinder learning. This study describes the quality of reports submitted during the first three years of England’s mandatory Learning from Deaths (LfD) program. While up to half of National Health Service (NHS) hospital trusts submitted data for all six regulatory statutes, a small minority did not submit any data. Three years in, the identification, reporting, and investigation of deaths has improved, but evidence of improved patient safety is still lacking.

The COVID-19 pandemic led to the rapid expansion and adoption of telehealth. The authors of this article discuss how to leverage the increased use of telehealth and propose a new organizational telehealth program model to help organizations develop and sustain safe, equitable, and high-quality telehealth programs.

In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.

Healthcare workers are at high risk of violence from patients, caregivers, and other healthcare workers. Researchers used three systems thinking methods (ActorMap, AcciMap, and PreventiMap) and stakeholder input to identify factors contributing to work-related violence incidents and interventions that can prevent or mitigate work-related violence.

A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.