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Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10(3):e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.  
Freeman K, Geppert J, Stinton C, et al. BMJ. 2021;374:n1872.
Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice. 
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40(11):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.
Segal M, Giuffrida P, Possanza L, et al. J Behav Health Serv Res. 2021;Epub Oct 21.
Effective integration of health information systems can improve decision making and care coordination across practice settings. This article discusses action-oriented safe practice recommendations from health information technology and electronic health record experts regarding integration of behavioral health and primary care. Recommendations focus on screening (e.g., integrated screening tools and triggers in electronic health records (EHRs)), documentation (e.g., streamlining behavioral health data entry), and sharing (e.g., using portals, secure messaging, or health information exchange to share information across care environments). The article also outlines the role of health IT developers, clinicians, and healthcare organizations in supporting behavioral health integration in primary care.
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18(9):1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
Silverglow A, Johansson L, Lidén E, et al. Scand J Caring Sci. 2021;Epub Aug 24.
Home care settings harbor unique patient safety challenges. This qualitative study identified three themes regarding care providers’ perceptions of providing safe care for frail older adults living at home – the role of the encounter and interaction, the responsibility of the caregiver, and the threat of insufficient organizational resources.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.
O’Dowd E, Lydon S, Lambe KA, et al. Fam Pract. 2021;Epub Sep 20.
Patient complaints can identify opportunities for patient safety improvement. This study explored whether an existing tool for measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool – can effectively analyze complaints specific to general practice. Key issues identified by the study involved relationships (e.g., communication, patient rights) as well as clinical and management issues.
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28(12):2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2021;Epub Oct 16.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Willis JS, Tyler C, Schiff GD, et al. Am J Med. 2021;134(9):1101-1103.
Telemedicine has become a more accepted care mode due to the COVID pandemic and general rural care access issues. This commentary suggests a 5-part framework for examining patient, physician, technological, clinical and health system influences on care management decisions that affect the safety of telediagnosis in primary care.

Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety. 

ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.
Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40(10):1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
Aasen L, Johannessen A‐K, Ruud Knutsen I, et al. J Clin Nurs. 2021;Epub Sep 28.
Patients receiving hospital-level care at home (hospital-at-home, (HAH) have fewer complications, better patient and family satisfaction, and better outcomes. This study describes nurses’ and physicians’ perspectives of pediatric HAH. Three themes evolved: building a trusting relationship with the child and family; performing essential skills; and acting as the “hub” between families and providers.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71(708):e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.