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Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic.

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Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.

This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids

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January 7, 2022

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.¹ Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.^1,2

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

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Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

The impact of health information management professionals on patient safety: a systematic review.

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Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38:248-258.

This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

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Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Reducing medication errors for adults in hospital settings.

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Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11:CD009985.

Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.

Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.

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Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

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Bickmore TW, Olafsson S, O'Leary TK. J Med Internet Res. 2021;23:e30704.

Patients and families increasingly access mobile apps, conversational assistants, and the internet to find information about health conditions or medications. In a follow up to an earlier study, researchers evaluated two approaches to determine the likelihood that patients would act upon the information received from conversational assistants.

Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.

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Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.

Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.

The benefits and harms of open notes in mental health: a Delphi survey of international experts.

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Blease CR, Kharko A, Hägglund M, et al. PLoS ONE. 2021;16:e0258056.

Allowing patients to access their own ambulatory clinical health record has benefits such as identification of errors and increased trust. This study focused on risks and benefits of patient access to mental health care records. Experts suggested the benefits would be similar to those seen in primary care, such as increased patient engagement, with the potential additional benefit of reduced stigmatization.

An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.

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Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.

Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.

Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.

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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33:mzab142.

Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning.

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

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Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.

This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.

Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?

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Shojania KG. Jt Comm J Qual Patient Saf. 2021;47:755-758.

Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

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Chaker A, Omair I, Mohamed WH, et al. Am J Health Syst Pharm. 2022;79:187–192.

The Institute for Safe Medication Practices recommends compounding pharmacies use technology and automation to improve patient safety. Researchers assessed the workflow and workforce requirements of one hospital’s sterile preparation center (SPC) following implementation of these recommendations. The average time to prepare each type of medication was used to determine pharmacy staffing workforce requirements.

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

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Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18:9206.

Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy.

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Freeman K, Geppert J, Stinton C, et al. BMJ. 2021;374:n1872.

Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice.

Novel telephone-based interactive voice response system for incident reporting.

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McNiven B, Brown AD. Jt Comm J Qual Patient Saf. 2021;47:809-813.

Errors and near misses reported via incident reporting systems can highlight emerging patient safety concerns; however, rates of reporting remain low. In this comparison study of web-based and interactive voice response systems (IVRS), the mean number of reports was higher for IVRS and length of time to complete the report was lower.

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