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Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
Oregon Patient Safety Commission.
This annual Patient Safety Reporting Program (PSRP) publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2021 data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon.
Organization: Association of periOperative Registered Nurses (AORN)
Event Description: This preparation course for the certification exam for ambulatory surgery infection preventionists will addresses all domains of the  exam and ASC-specific responsibilities: Employee health Surveillance for surgical site infections Developing and implementing an infection prevention and control - program Performing risk assessments Reporting to the governing body Coordinating the interdisciplinary team that determines a facility’s program
Event Location: Online
Date: On Demand and Live Options (Next Course Fall 2022)
Event Fee: Fee Associated
CE or CME Offered? Yes
Institute for Safe Medication Practices. August 4-5, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Singh M, Collins L, Farrington R, et al. Diagnosis (Berl). 2022;9:184-194.
Clinical reasoning is an essential component of diagnostic safety. This paper describes the development of a new curriculum to improve clinical reasoning skills and processes in medical students. The curriculum uses several educational strategies (e.g., classroom teaching, simulation training, patient encounters) during pre-clerkship and clerkship to improve clinical reasoning skills across several domains (theory, patient assessment, diagnosis, and shared decision-making).
Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.
When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.
Mortensen M, Naustdal KI, Uibu E, et al. BMJ Open Qual. 2022;11:e001751.
A 2011 systematic review identified nine tools to assess patient safety competence in nurses. This review identified multiple instruments released since that review; the most frequently used was the Health Professional Education in Patient Safety Survey (H-PEPSS). The authors suggest future research should consider including ethics in patient safety and responsiveness to change over time.
Ong N, Mimmo L, Barnett D, et al. Dev Med Child Neurol. 2022;Epub May 16.
Patients with intellectual disabilities may be at higher risk for patient safety events. In this study, researchers qualitatively analyzed hospital incident reporting data and identified incidents categories disproportionately experienced by children with intellectual disabilities. These incident categories included medication-intravenous fluid issues, communication failures, clinical deterioration, and care issues identified by parents.

Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.
A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
Iredell B, Mourad H, Nickman NA, et al. Am J Health Syst Pharm. 2022;79:730-735.
The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.
Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.
Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.
Peivandi S, Ahmadian L, Farokhzadian J, et al. BMC Med Inform Decis Mak. 2022;22:96.
Speech recognition software is a potential strategy to reduce documentation burden and burnout. This study compared the accuracy handwritten nursing notes versus online and offline speech recognition software. Findings indicate that the speech recognition software was accurate but created more errors than handwritten notes.

ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 5.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;Epub May 6.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
Joseph AL, Monkman H, Kushniruk AW, et al. Stud Health Technol Inform. 2022;2022:535-539.
Patient portals allow patients and their caregivers to read clinical notes, view test results, and communicate with their provider, with the goal of improving patient safety. This scoping review found limited evidence of improved patient safety with the use of patient portals. Additionally, the authors found multiple naming conventions, such as patient portal, personal health record, and personal medical record.