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Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;17:e1285-e1295.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77:3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
Hada A, Coyer F. Nurs Health Sci. 2021;23:337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;46:877-886.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36:3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Schouten B, Merten H, Spreeuwenberg PMM, et al. J Patient Saf. 2020;17:166-173.
Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.
Rodrigo Rincón I, Irigoyen Aristorena I, Tirapu León B, et al. BMC Health Serv Res. 2021;21:31.
Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.

Project Nurture provides patients with substance use disorder (SUD) prenatal care, inpatient maternity care, postpartum care, and infant pediatric care. Women enrolled in the program receive Level 1 addiction treatment (i.e., outpatient services) from an integrated care team that includes MDs, nurse practitioners, doulas, certified recovery mentors, certified alcohol and drug counselors, and social workers and other mental health professionals. If indicated, they can also receive medication-assisted treatment (MAT) using methadone or buprenorphine.

Blake JWC, Giuliano KK. AACN Adv Crit Care. 2020;31:357-363.
The COVID-19 pandemic has led to many changes in health care delivery. This article discusses one common process change – moving medical devices (such as intravenous (IV) infusion pumps) away from the bedside – and how to support nursing clinical decision-making during IV infusion therapy.  
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  
Kanaan AO, Sullivan KM, Seed SM, et al. Pharmacy (Basel). 2020;8:225.
The COVID-19 pandemic has affected the ability of pharmacists to ensure medication safety. This article uses case scenarios to highlight challenges encountered due to the COVID-19 pandemic that required changes in pharmacist roles. Strategies to overcome challenges related to monitoring medications used to treat patients with COVID-19, preventing errors with laboratory reporting, and managing drug shortages are discussed.