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Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2022;31:297-307.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17:e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.  

Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.

Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

Surgical patients are at high risk for harm, should errors occur. This special issue covers areas of concern in perioperative anesthesia care that include patient allergies, age, sex and gender considerations, and incident reporting system effectiveness.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4:e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Zheng WY, Lichtner V, Van Dort BA, et al. Res Soc Admin Pharm. 2021;17:832-841.
This systematic review sought to determine the impact of automated dispensing cabinets (ADCs), barcode medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) used by hospitals in reducing controlled substance medication errors in hospitals. Overall, only 4 studies (out of 16) focused directly on controlled medications. A variety of types of errors (e.g., log-in, data, entry, override) compromised patient safety. High-quality targeted research is urgently needed to evaluate the risks and benefits of medication-related technology.

Rockville, MD: Agency for Healthcare Research and Quality. February 9, 2021. PA-21-164.

 

Digital strategies hold promise for improving point-of-care efficiency, communication, and safety. This funding opportunity will support research exploring how digital technology can be designed and implemented to improve the quality of healthcare services delivery at the point of care. Areas of interest include the use of patient-facing technologies, development of advanced analytics, and improvements in point-of-care clinical decision making.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
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.
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Han SM, Greenfield G, Majeed A, et al. J Med Internet Res. 2020;22:e23482.
Social distancing precautions due to the COVID-19 pandemic have led to increased use of telehealth. The authors of this systematic review conclude that there is insufficient evidence to determine whether remote prescribing in primary care changes antibiotic prescribing practices. Future research should further assess remote prescribing to ensure there are no negative impacts on antimicrobial stewardship.  
Jazieh AR, Akbulut H, Curigliano G, et al. JCO Glob Oncol. 2020;6):1428-1438.
Patients with chronic health needs, including those with cancer, and their providers face numerous challenges during the COVID-19 pandemic. Survey results from 356 health care centers across 54 countries indicate that the impact of the COVID-19 pandemic on cancer care is widespread. Many centers reported challenges in delivering care, reduction in services, lack of personal protective equipment, staffing shortages, and limited access to medications. Respondents also reported potential patient harm due to interruptions in cancer-specific and non-cancer care.
Murphy ZR, Wang J, Boland MV. JAMA Netw Open. 2020;3:e2012529.
This cross-sectional analysis explored associations between electronic health record (EHR) implementation above meaningful use performance thresholds and changes in safety and patient satisfaction. Increasing EHR implementation of computerized physician order entry (CPOE) was not straightforwardly associated with improvements in safety and satisfaction.
Nygaard AM, Selnes Haugdahl H, Støre Brinchmann B, et al. J Clin Nurs. 2020;29:3822-3834.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes.  This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Kern-Goldberger AR, Adelman J, Applebaum JR, et al. Obstet Gynecol. 2020;136:161-166.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.

ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)

This alert discusses medication errors that have been reported to the Food and Drug Administration involving the preparation, administration, and storage of two formulations of the investigational COVID-19 treatment remdesivir. Recommendations to guide safe practice include use of standard order sets and dosing clarifications.
Maurer NR, Hogan TH, Walker DM. Med Care Res Rev. 2021;78:643-659.
This systematic review examined effectiveness of hospital- or system-wide interventions in reducing healthcare-associated infections (HAIs). The review identified several strategies for reducing HAIs, including enhanced environmental cleaning using disinfection technologies; EHR implementation; multimodal infection control programs; multichannel hand hygiene promotion; and hospital-wide cultural transformations. The review identifies approaches meriting additional research and exploration.
Logan MS, Myers LC, Salmasian H, et al. J Patient Saf. 2021;17:e1726-e1731.
This article describes an innovative expert consensus process to generate a contemporary list of chart-review based triggers and adverse event measures for assessing the incidence of inpatient and outpatient adverse events. A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high clinical importance deemed suitable for chart review and 198 were found suitable for electronic surveillance; 192 items were suitable for both.