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Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

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Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Encouraging patients to speak up about problems in cancer care.

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Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.

Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.

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.

Medication safety issues with newly authorized PAXLOVID.

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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.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

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

Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings

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January 7, 2022

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.

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”).

National Healthcare Quality and Disparities Reports.

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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.

Association of differences in treatment intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure control.

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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.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey

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Stahl K, Groene O. PLoS ONE. 2021;16:e0259252.

Patient safety in ambulatory care is an emerging focus of measurement and improvement efforts. This cross-sectional study including patients from 22 ambulatory care practices in Germany found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors discuss how different approaches to voluntary reporting can influence measurement of patient experience.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

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Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2021;Epub Nov 18.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Burnout, engagement, and dental errors among U.S. dentists.

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Yansane A, Tokede O, Walji MF, et al. J Patient Saf. 2021;17:e1050-e1056.

Clinician burnout is a known threat to patient safety. This survey of a national sample of dentists found that approximately 1 in 10 respondents reported high levels of burnout and 50% of respondents reported a perceived dental error in the last 6 months. Efforts to minimize burnout among dentists may help improve patient safety.

Complaints to the Parliamentary and Health Service Ombudsman.

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London, UK: Parliamentary and Health Service Ombudsman.

The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication series provides information about complaints submitted to trusts to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.

US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019.

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Mital R, Lovegrove MC, Moro RN, et al. Pharmacoepidemiol Drug Saf. 2022;31:225-234.

Accidental ingestion of over-the-counter (OTC) cold and cough medicines (CCMs) among children can result in adverse events. This study used national surveillance data to characterize emergency department (ED) visits for harms related to OTC CCM use and discusses differences by patient demographics, intent of use, and concurrent substance use.

Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.

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Wallis KA, Elley CR, Moyes SA, et al. BJGP Open. 2022;6:BJGPO.2021.0129.

Common high-risk medications such as antiplatelets and non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to cause serious patient harm. This randomized trial examined the usefulness of an existing intervention to support safer prescribing in general practice to improve safe high-risk prescribing.

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Understanding SOPS Surveys--A Quick Primer for New Users.

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Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts.

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.

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