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1 - 20 of 1165

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33(3):mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;Epub Aug 16.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326(5):411-419.
Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering. 
Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.
Adverse drug events are a common source of harm in both inpatient and ambulatory patients. This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical settings, and that older adults are at increased risk. Medications to treat high blood pressure and arrhythmias were the most common cause of medication harm.

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19. 

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Geneva: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2021;Epub Jul 15.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;Epub Jun 30.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Nævestad T-O, Storesund Hesjevoll I, Elvik R. Accid Anal Prev. 2021;159:106228.
Healthcare organizations are increasingly investing in promoting culture of safety to improve patient safety outcomes but few, if any, regulations exist influencing safety culture in healthcare. In a review of how regulators influence safety culture in several high-reliability fields, the authors identified six relationships between regulators and safety behavior and accidents. If healthcare regulators are to successfully influence safety culture in healthcare, attention must be paid to each relationship.
Sujan M, Habli I. BMJ Qual Saf. 2021;Epub May 27.
This commentary discusses the use of “safety cases” to communicate the safety of a product, system or service in industry (e.g., aviation, defense, railways). Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare to support the safe adoption of digital health innovations.

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summaries ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.
Osborne V. Curr Opin Psychiatry. 2021;34(4):357-362.
The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30(7):525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Worsham CM, Woo J, Jena AB, et al. Health Aff (Millwood). 2021;40(6):970-978.
Adolescent patients transitioning from pediatric to adult medicine may experience patient safety risks. Using a large commercial insurance claims database, the authors compared opioid prescribing patterns and risk for opioid-related adverse events (overdose, opioid use disorder, or long-term use) among adolescents transitioning from “child” to “adult” at 18 years of age. The authors estimate a 14% increased risk for an opioid-related adverse outcome within one year when “adults” just over age 18 years were prescribed opioids that would not have been prescribed if they were under 18 years and considered “children.” The authors discuss how systematic differences in how pediatric and adult patients may be treated can lead to differences in opioid prescribing.

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  
Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Int J Environ Res Public Health. 2021;18(10):5335.
The beginning of the COVID-19 pandemic immediately changed how patients sought healthcare. This study analyzed the change frequency of diagnoses made in 2019 compared to 2020 in one region of Spain. On average, the number of diagnoses declined 31% from 2019 to 2020, with cancer diagnoses declining by nearly 50%. As COVID-19 cases continue to decrease in many areas in 2021, the authors recommend local, regional, and national public health leaders prioritize plans to target under-diagnosed conditions.

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.