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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.

Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.
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. 
Gould D, Purssell E, Jeanes A, et al. BMJ Qual Saf. 2021;Epub Jul 16.
The “My Five Moments for Hand Hygiene” framework is promoted by the World Health Organization to decrease healthcare-associated infections (HAIs). This article identifies five limitations of the Five Moments and proposes solutions to improve hand hygiene, including capitalizing on infection control measures brought about by the COVID-19 pandemic.
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.
Hernández-Prats C, López-Pintor E, Lumbreras B. Res Social Adm Pharm. 2021;Epub Jul 12.
Clinical pharmacists play an important role in ensuring patient safety, particularly in interventions aimed at reducing polypharmacy. This review focused on interventions involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure. Findings indicate interventions are most successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure medications are followed.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Academic Medical Center Patient Safety Organization.

Patient Safety organizations (PSO) are in a unique position to educate their members and the larger community on patient safety challenges. This PSO resource collection includes guidelines, papers and alerts drawn from the experiences the membership group to inform action covering topics such as virtual visits and inter-hospital transfers.
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.
Jungo KT, Streit S, Lauffenburger JC. BMC Geriatr. 2021;21(1):163.
The purpose of this retrospective cohort study of older adults with polypharmacy and multimorbidity was to identify patient characteristics associated with new prescriptions for potentially inappropriate medications (PIMs). Patients who are male, 85 years and older, diagnosed with heart disease, and have an increased number of ambulatory visits were most at risk for being newly prescribed PIMs. The authors recommend these characteristics be considered when developing interventions to reduce PIMs in the geriatric population. 
Brown NJ, Wilson B, Szabadi S, et al. Patient Saf Surg. 2021;15(1):19.
At the start of the COVID-19 pandemic, many elective surgical procedures were canceled or postponed due to limited resources (e.g., personal protective equipment, diagnostic tests, redeployment of healthcare personnel). This commentary discusses the implications of rationed non-urgent surgical care within the context of medical ethics: beneficence, non-maleficence, justice, and autonomy. The authors developed an algorithm to guide surgical teams through the decision-making process of delaying non-urgent surgical procedures, if necessary, in the future. 
Calder LA, Perry J, Yan JW, et al. Ann Emerg Med. 2021;Epub Feb 23.
Prior research has found that some patients may be at risk for adverse events after discharge from the emergency department (ED). This cohort study analyzed adverse events occurring among patients discharged from the ED with cardiovascular conditions and identified several opportunities for improving safe care, such as adherence to evidence-based clinical guidelines and strengthening dual diagnosis detection.
Calcaterra SL, Lou Y, Everhart RM, et al. J Gen Intern Care. 2021;36(1):43-50.
Opioid use is an ongoing patient safety concern. This large retrospective cohort study found that patients who received oral or intravenous opioids during an urgent care visit were more likely to receive opioids at discharge, and progress to chronic opioid use

Odor PM, Bampoe S, Lucas DN, et al the Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Anaesthesia. Epub 2021 Jan 12.

Accidental patient awareness during anesthesia can result in significant patient distress and harm. This prospective cohort study, including 3,115 patients, identified high rates of accidental awareness during general anesthesia for obstetric surgery. In some patients, accidental awareness resulted in distressing experiences, paralysis, or a provisional diagnosis of post-traumatic stress disorder.

Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021.

Lack of access to ventilators during the COVID-19 crisis has necessitated care compromises to support multiple patients. This situation can reduce the effectiveness of monitoring patients on shared devices and introduce other challenges. This communication provides insights to enhance the safety of multiple-patient ventilator use.
Vimercati L, De Maria L, Quarato M, et al. Int J Infect Dis. 2021;102:532-537.
The pressures faced by hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This single-setting study conducted in Italy including 5,750 healthcare workers compared the prevalence of COVID-19 infection among those in contact with COVID-19 patients and those working elsewhere in the hospital. The prevalence among exposed healthcare workers was 0.7% and 0.4% among all healthcare workers at this hospital. The authors conclude that correct use of personal protective equipment (PPE) and early identification of symptomatic healthcare workers can reduce nosocomial transmission.  
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;Epub Nov 6. .
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2021 NPSGs reflect no changes from the 2020 goal set. 
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156(1):76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.