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Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326:411-419.
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. 
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.
Aldila F, Walpola RL. Res Social Adm Pharm. 2021;17:1877-1886.
Older adults are at increased risk of medicine self-administration errors (MSEs) due to polypharmacy, cognitive decline, and decline in physical abilities. In this review, incorrect dosing was the most common MSE; the most common factor influencing the errors is complex medication regimens due to the need for multiple medications. Additional research is needed into how community pharmacists can assist older adults at risk of MSE.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Gualano MR, Lo Moro G, Voglino G, et al. Expert Opin Pharmacother. 2021;22:1051-1059.
Medication errors are a major source of preventable patient harm. Based primarily on data from national poison centers, this review summarizes the incidence self-administered medication errors in domestic settings and the role of healthcare professionals in ensuring that medication instructions are clear and understood by patients and caregivers.
Barreveld AM, McCarthy RJ, Elkassabany N, et al. Anesthesiology. 2020;132:1558-1568.
This article discusses the impact of a 6-month opioid use educational program for anesthesiologists on opioid-related harm among hospitalized adults. The program was implemented at 31 hospitals and outcomes were compared to 33 control hospitals. The researchers did not identify any significant reduction in opioid adverse events or altered opioid use in hospitalized patients in the intervention hospitals, as compared to the control hospitals.  
Duhn L, Godfrey C, Medves J. Health Expect. 2020;23:979-991.
This scoping review characterized the evidence base on patients’ attitudes and behaviors concerning their engagement in ensuring the safety of their care. The review found increasing interest in patient and family engagement in safety and identified several research gaps, such as a need to better understand patients’ attitudes across the continuum of care, the role of family members, and engagement in primary care safety practices.
Barth RJ, Waljee JF. JAMA Surg. 2020;155:543-544.
This commentary discusses the harms of opioid overprescribing, particularly among opioid-naïve patients. The authors suggest that opioid dependence, abuse, or overdose in an opioid-naïve patient undergoing surgery should be considered a “never event” and discuss strategies for appropriate prescribing by surgeons.
Kumar PR, Nash DB. Am J Med Qual. 2020;36:185-196.
The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting since 2016. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.
Fearon NJ, Benfante N, Assel M, et al. Jt Comm J Qual Patient Saf. 2020;46:410-416.
Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.
Meyers RS, Thackray J, Matson KL, et al. J Pediatr Pharmacol Ther. 2020;25.
This article describes the development of the Key Potentially Inappropriate Drugs in Pediatrics, or “KIDs” List, intended to create a standard of care for safe medication use in pediatric populations. A panel of seven pediatric pharmacists from the Pediatric Pharmacy Association developed an evidence-based list of candidate drugs which was then peer-reviewed and subjected to a public comment period. The final KIDs List includes 67 drugs/drug classes; most require a prescription and are available in various dosage formulations.
Mikosz CA, Zhang K, Haegerich TM, et al. JAMA Netw Open. 2020;3.
Adherence to prescribing guidelines for appropriate opioid dosing and duration can decrease the risk of opioid-related harm. In this retrospective analysis of nationally representative outpatient claims data, researchers found that over a 4-6 month period, 28% of Medicaid and 35% of privately-insured patients had at least one pain-related visit and 35% of all enrollees had one or more opioid prescriptions. Opioid prescribing rates varied depending on the specific medical indication and the patient’s opioid prescribing history. The researchers found that prescribing rates of many pain medical indications were not always aligned with current guidelines. For example, patients with chronic non-cancer pain conditions undergoing long-term opioid therapy were commonly prescribed daily doses above the threshold for which adverse events, such as overdose, are increased.
Sarasin DS, Brady JW, Stevens RL. Anesth Prog. 2020;67(1):48-59. 
This two-part series discusses anesthesia- and sedation-related medication errors and adverse events in healthcare and dentistry (part 1) and how these errors impact dentistry and approaches to address these issues within a dental anesthesia medication safety paradigm - the Dental Anesthesia Medication Safety Paradigm (DAMSP) - which offers four general guidelines for reducing anesthesia medication errors and adverse drug events in dentistry (part 2).

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Dager WE, Ansell J, Barnes GD, et al. Jt Comm J Qual Saf. 2020;46:173-180.
The Joint Commission previously issued a sentinel event alert for medication errors relating to anticoagulant therapies and included them as part of the National Patient Safety Goal (NPSG) program. This commentary discusses the eight 2019 NPSGs for anticoagulants: dosing protocols; anticoagulant reversal; perioperative management; laboratory monitoring; anticoagulant safety; patient education; unit dose packaging, and; programmable pumps.  
Garfield S, Furniss D, Husson F, et al. BMJ Qual Saf. 2020;29:764-773.
This mixed-methods study of patients, caregivers and healthcare professionals explores how patient-held medication lists (such as paper medication lists, medication diaries, or apps) can support patient safety. Patient-held lists can improve medication safety by improving the accuracy of medication reconciliation, identifying potential drug interactions, and facilitating communication.
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.