Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
21 - 40 of 16981

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

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

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

Institute for Healthcare Improvement. April 6 - June 15, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
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”).

Joint Commission.

Sentinel events are a primary indicator of patient safety in hospitals that enable learning through reporting to the Joint Commission. This website provides access to statistics, alerts, policies and tools to assist organizations in using sentinel events for their medical error reduction efforts.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Organization: American College of Surgeons (ACS)
Event Description: The self-paced, online course is intended for anyone working in a health care setting who is still learning the foundations of quality improvement, regardless of their role. It includes six modules: Introduction to Quality Improvement The Quality Improvement Process Data Measurement and Analysis Change Management Patient Safety Leadership and Teamwork for QI
Event Location: Online
Date: On Demand
Event Fee: Fee Associated
CE or CME Offered? Yes
Organization: Institute for Safe Medication Practices (ISMP)
Event Description: ISMP's series of webinar on Safety topics. Most programs provide required medication/patient safety continuing education credits for pharmacists, pharmacy technicians, and nurses.
Event Location: Online 
Date: On Demand
Event Fee: Free
CE or CME Offered? Yes
Fontil V, Pacca L, Bellows BK, et al. JAMA Cardiol. 2022;7:204-212.
Racial and ethnic inequities are increasingly being linked to health disparities. This study of more than 16,000 patients explored the association between race and ethnicity and blood pressure control. Findings suggest racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in blood pressure control.
Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.

Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.  

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.
Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21:648.
Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.
Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.
Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.
Draus C, Mianecki TB, Musgrove H, et al. J Nurs Care Qual. 2022;37:110-116.
“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.
Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2021;Epub Oct 21.
A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.
Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43:1693-1704.
While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.