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Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.
Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;Epub Aug 31.
Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.

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.

Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28(7):1526-1533.
Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28(6):1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Allison MK, Marshall SA, Stewart G, et al. J Emerg Med. 2021;Epub Jun 29.
Transgender and gender nonbinary (trans/NB) people can face discriminatory behaviors when accessing health care services. Trans/NB patients were interviewed about their experiences accessing care in emergency departments. Four themes were uncovered: 1) system and structural issues; 2) interactions with clinicians/staff; 3) perceptions of clinician knowledge and education; and 4) impact on future health and healthcare access. Recommendations for improvement were provided at the system and clinician level.
Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;Epub Jun 9.
Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.
Cifra CL, Sittig DF, Singh H. BMJ Qual Saf. 2021;30(7):591-597.
Accurate and timely feedback about patient outcomes can inform and improve future clinical decision-making; however, many barriers exist that prevent effective feedback. This article suggests a sociotechnical approach using information technology (IT) to provide clinician feedback. Feedback sent using the electronic health record can be provided asynchronously, by any member of the care team, and in a structured format to ensure relevance and usefulness.
Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;Epub May 31.
Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.
Walters GK. J Patient Saf. 2021;17(4):e264-e267.
The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.
Geva A, Albert BD, Hamilton S, et al. Pediatr Crit Care Med. 2021;Epub May 4.
Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER. The eSIMPLER checklist took less time to complete, had higher user satisfaction, and improved adherence to best-practices.
Killin L, Hezam A, Anderson KK, et al. Jt Comm J Qual Patient Saf. 2021;47(7):438-451.
Medication errors at hospital discharge are a common cause of medication errors and adverse drug events (ADE). This review compared three types of discharge medication reconciliation: paper-based, electronic, and enhanced. Results suggest electronic medication reconciliation reduced the odds of a medication discrepancy or ADE, as compared to paper-based. Results were mixed on enhanced medication reconciliation.
Pruitt ZM, Howe JL, Hettinger AZ, et al. J Patient Saf. 2021;Epub Apr 20.
Electronic health record (EHR) usability can affect clinicians’ ability to provide safe patient care. Thematic analysis of interviews with emergency medicine physicians reveal that the most common perceived usability strength was visual display of the EHR system, and the most common shortcoming was lack of workflow support (e.g., a workflow mismatch between the EHR system and how clinicians use the system to accomplish tasks).
Freise L, Neves AL, Flott K, et al. JMIR Form Res. 2021;5(2):e19074.
Patient access to electronic health records (EHRs) can improve health outcomes but is not without concern. This survey of users of a patient portal providing online access to EHRs identified several barriers to understanding information contained in their electronic records, including medical terminology, interpretation of test results, and information display. These barriers signal potential avenues for improving systems providing patient access to their health records.
Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11(5):865-872.
The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.   
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28(4):685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Sigal A, Shah A, Onderdonk A, et al. Pain Med. 2020;Epub Oct 18.
Reducing opioid-related overdoses and deaths is a national patient safety priority. This study analyzed the impact of implementing three quality improvement interventions on the opioid prescribing practices of emergency providers at one hospital – the implementation of a prescription drug monitoring program, clinical education on alternatives to opioids, and electronic health record (EHR) process changes. Findings indicate that these three approaches can decrease the amount of opioids prescribed in an acute ED setting.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8(3):340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28(1):167-176.
Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.