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Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40:1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4:e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;43:324-339.
The goal of the patient centered medical home (PCMH)  model is to reorganize primary care to provide team-based, coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety concerns (e.g., medication safety, diagnostic error, treatment delays, communication or coordination errors) in the context of the PCMH model and explore variability in the implementation of patient safety practices.
Krancevich NM, Belfer JJ, Draper HM, et al. Ann Pharmacother. 2022;56:52-59.
Prescribing opioids to opioid-naïve patients after hospital discharge may lead to chronic use. This study evaluated long-term opioid use among patients admitted directly to the ICU and who received intravenous opioids. While long-term opioid use was more common among patients who received an opioid prescription at discharge, the authors did not find a significant relationship between ICU opioid prescribing in opioid-naïve patients and long-term opioid use. The authors suggest future research focus on transitions from hospital to home or other post-acute sites to reduce inappropriate opioid use.
Kruse CS, Mileski M, Syal R, et al. Technol Health Care. 2020;29:1-14.
Health information technology (HIT) can promote patient safety in many settings. This systematic review found that HIT, such as computerized provider order entry (CPOE) systems, can improve safe prescribing practices in long-term care settings, including improved documentation and clinical processes, and fewer medication errors.
Contreras J, Baus C, Brandt C, et al. J Am Pharm Assoc (2003). 2021;61:e94-e99.
Naloxone administration is used to mitigate the effects of opioid overdose. The FDA recommends health care professionals educate patients about naloxone when prescribing opioid medications. In this audit of community pharmacists, researchers found that naloxone counseling commonly often excluded concepts important to patient safety, such as assessment of opioid misuse or abuse, possible adverse effects, and naloxone storage.
Lai AY. J Am Board Fam Med. 2020;33:754-764.
This study used qualitative methods to compare how patients versus front clinicians, administrators and staff conceptualize patient safety in primary care. Findings indicate that work function-based conceptualizations of patient safety (e.g., good communication and providing appropriate, timely care) better reflect the experiences of healthcare personnel and patients rather than domain-based conceptualizations (e.g., diagnosis, care transitions, and medications).
Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
Hirsh AT, Anastas TM, Miller MM, et al. Am Psychol. 2020;75:784-795.
Potentially inappropriate opioid prescribing increases risk of patient harm and misuse. This study used videos and written vignettes to explore how patient race and previous opioid misuse behaviors impact providers’ risk assessment for future prescription opioid-related problems. Findings indicate that black patients were perceived by both residents and fellows to be at greater risk for future adverse events and diversion regardless of previous misuse history, suggesting that racial minorities with chronic pain may be vulnerable to unintended consequences of public health efforts to reduce opioid prescribing.
Brown KW, Carlisle K, Raman SR, et al. Health Aff (Milwood). 2020;39:1737-1742.
Over the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays related to opioid use. Based on Medicaid claims in North Carolina, prescribers of opioids for children were most commonly physicians and dentists. More than 3% of children ages 1 to 17 years had at least one opioid prescription filled annually; 76.6 children per 100,000 experienced an opioid-related adverse event or other harm. Adolescents ages 15 to 17 years disproportionately experienced these harms compared to younger age groups. Black and urban children were less likely to fill opioid prescriptions or experience adverse events, but they were more likely to experience other opioid-related harm, such as abuse or dependence.   
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  
Naseralallah LM, Hussain TA, Jaam M, et al. Int J Clin Pharm. 2020;42:979-994.
Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.
Talcott WJ, Lincoln H, Kelly JR, et al. Pract Radiat Oncol. 2020;10:312-320.
Peer review of radiation oncology patient treatment plans can help prevent harm and reduce errors. In this prospective blinded study, researchers generated treatment plans with simulated errors and randomly inserted these treatment plans into weekly chart rounds to assess the effectiveness of peer review on error detection. Overall detection rate of clinically significant problematic plans was 55%. The authors suggest that error detection could be significantly improved by shortening chart rounds and routine insertion of problematic plans into rounds.
Ochalek TA, Cumpston KL, Wills BK, et al. JAMA. 2020;324:1673-1674.
The opioid epidemic is an ongoing patient safety issue. This study examined the impact of the COVID-19 state emergency declaration on nonfatal, unintentional opioid-related overdoses. The authors identified a greater number of opioid overdoses occurring between March 1 to June 30, 2020 compared to March 1 to June 30, 2019, and that Black patients made up a larger proportion of the overdose visits compared with the previous year. These results highlight the potential impact of COVID-19 on racial/ethnic disparities.

Rockville, MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Pub. No. 20-0048.

AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2020, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between July 2012 and December 2019. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. This iteration of the chartbook contains an additional 619,111 reports not included in the prior NSPD chartbook.  
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.