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.

Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight. Findings indicate that patients who spent an overnight in the ED had a higher in-hospital mortality rate, increased risk of adverse events, and longer length of stay; this risk was exacerbated for patients with limited functional status.

A poor work environment can have a negative impact on quality and safety of patient care. This study of primary care nurses in Portugal shows that better work practice environments are associated with higher quality of care, patient safety, and safety culture. Nursing foundations for quality of care and collegial nurse-physician relations were the highest rated survey dimensions.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

Current Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations limit resident work hours (no more than 80 hours per week or 24-28 consecutive hours on duty) in an effort to improve both resident and patient safety. This nationally representative survey found that over 90% of US adults disagree with the current duty hour policies, with 66% of respondents supporting additional limits on duty hours (to no more than 40 hours per week or 12 consecutive hours).

Reducing or preventing inpatient falls is a common focus of patient safety improvement efforts in hospitals. This study in three orthopedic and three geriatric wards describes multidisciplinary communication about falls prevention strategies. Risk assessments and categorization (e.g., high- or low-risk) were discussed in conjunction with strategies to focus on modifiable risk factors.

Healthcare has borrowed many safety practices from aviation such as checklists, crew resource management, and safety culture. In this study, interviews with aviation experts identify non-technical skills that leaders require in a safety culture environment which the authors adapt for surgical leaders. The core attribute was "humble confidence," with three additional domains: management of risk, management of opportunity, and management of people. The authors developed the Safety Leadership Assessment Matrix (SLAM) to assess these non-technical skills in surgeon leaders.

Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.

Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate sentinel events. In this study, members of an RCA committee were interviewed before and after an RCA investigation to elicit their experiences and assess compliance with the Norwegian RCA process. Organizational factors and team composition presented challenges, particularly the inclusion of staff closely involved with the incident under investigation.

Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.

Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.

Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Nosocomial infections remain a persistent patient safety issue and can lead to serious patient harm. This article describes one Israeli hospital’s experience using department-level investigations to reduce the incidence of nosocomial bloodstream infections. Study findings demonstrated that department-level investigations coupled with increased staff awareness led to significant reductions in nosocomial bloodstream infections.

Patient safety improvement efforts involve financial expenditures, which means that hospital leaders must evaluate their return on investment. This study examines the association of several quality-of-care measures and hospital profitability as measured by patient revenue per adjusted discharge. Better patient satisfaction, lower readmission rates, and three of the four Hospital Value-Based Purchasing Program (HVBP) domains were associated with improved financial outcomes.

Authentic leadership principles emphasize the influence of positive psychological capacities to foster self-awareness and self-regulated positive behaviors. This qualitative study used podcast transcripts to explore the experiences of senior leadership during the COVID-19 pandemic and the role of authentic leadership principles. The researchers identified several behaviors demonstrating authentic leadership and discuss its influence of psychological safety, particularly during a crisis.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.