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Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17(5):341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Institute for Safe Medication Practices. December 2-3, 2021.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6(4):e425.
Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47(10):646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2(1):63.
Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;Epub May 20.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Manias E, Bucknall T, Hutchinson AM, et al. Expert Opin Drug Saf. 2021:1-19.
Medication errors are a common cause of preventable harm in long-term care facilities. This systematic review explored how residents and families engage in medication management in aged care facilities. Factors hindering effective engagement included insufficient communication between residents, families, and providers; families’ hesitation about decision making; and lack of provider training.
Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;Epub Jun 13.
The goal of the patient centered medical home (PCMH)  model is to reorganize primary care to provide team-based, coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety concerns (e.g., medication safety, diagnostic error, treatment delays, communication or coordination errors) in the context of the PCMH model and explore variability in the implementation of patient safety practices.
Green AR, Aschmann H, Boyd CM, et al. JAMA Netw Open. 2021;4(4):e212633.
Effective communication between patient and provider is key to successful deprescribing.  Participants in this study were asked to rate potential phrases a clinician may use to explain why stopping or reducing a medication is important. The most preferred phrase involved an explanation of risk of side effects associated with the medications while the least preferred options focused on the effort involved in taking the medication and “this medication is unlikely to help you function better”. Understanding the patient’s priorities can help frame the conversation around deprescribing.
Pathak S, Blanchard CM, Moreton E, et al. J Health Care Poor Underserved. 2021;32(2):737-750.
The growing use of telehealth can increase patient access to timely care, but also presents patient safety considerations. The use of telehealth to deliver health care services continues to expand. This systematic review included six studies examining safety and quality issues in community pharmacy-based telepharmacy services. Findings suggest that telepharmacies perform similarly or slightly better than traditional pharmacies in terms of medication safety and adherence, but the authors note a high risk of bias amongst the studies which limits the ability to draw definitive conclusions about patient safety and quality-related outcomes.
Kabir R, Liaw S, Cerise J, et al. J Pharm Pract. 2021:089719002110212.
The best possible medication history (BPMH) is the gold standard of medication reconciliation of a patient’s prescribed and over-the-counter medications. In this study, Certified Pharmacy Technicians (CPhTs) obtained BPMH from patients admitted through the emergency department. In Quality Assurance reviews, the CPhTs identified medication discrepancies at a similar rate to pharmacists, indicating that CPhTs may be a cost-effective alternative to pharmacists in obtaining BPMH.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51(4):520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.