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Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17(1):e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156(1):76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.

Oglethorpe A. Women's Health. November 4, 2020.

Skin condition diagnosis is a visual activity that is vulnerable to error. This article highlights how conditions such as psoriasis and skin cancer can be misdiagnosed. The piece shares recommendations for patients to obtain an accurate diagnosis such as seeking a second opinion and preparing for appointments with notes and questions.

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   

Mann B. All Things Considered. National Public Radio. October 5, 2020.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem. 
Haydar B, Baetzel A, Stewart M, et al. Anesth Analg. 2020;131(1):245-254.
Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.
Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146(4):e20192057.
This article describes the implementation and results of catheter-associated urinary tract infection (CAUTI) prevention efforts by a large network of children’s hospitals between 2011 and 2017. Prevention efforts included catheter insertion and maintenance bundles. After implementation of the bundles, CAUTI rates across the network decreased by 61.6%.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2020;76(2):230-240.
This study assessed the performance of an automated emergency department (ED) trigger tool designed to identify a more efficient sample of adverse event cases for chart review. Beginning with a set of 97 candidate triggers, researchers identified those triggers associated with adverse events and arrived at a narrowed set of 30 triggers, eliminating almost half of the population of records eligible for manual review. This computerized query may eliminate the need for manual screening for triggers.  
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46(10):591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.
Aaron M, Webb A, Luhanga U. J Grad Med Educ. 2020;12(4):415-424.
In this narrative review, the authors examined current literature on effective strategies to increase patient safety event reporting among residents and trainees. The most sustainable interventions combined strategies that successfully minimized physician involvement time, incorporated accessible event reporting into existing electronic health record systems, and became integrated into the normal patient care workflow. The authors also noted a lack of studies involving residents and trainees in root cause analysis following event reporting.
DiSilvio B, Virani A, Patel S, et al. Crit Care Nurs Q. 2020;43(4):413-427.
This article discusses several aspects essential to surge planning and preparing for the COVID-19 pandemic, including surge planning, limiting health care worker exposure, logistics for medication delivery, delivering emergent care in patients with COVID-19, and safe practices for patient transport.
Kesselheim JC, Shelburne JT, Bell SK, et al. Acad Pediatr. 2021;21(2):352-357.
This article reports findings from a survey of pediatric trainees at two large children’s hospitals on attitudes and behaviors in regard to speaking up about traditional safety threats and unprofessional behavior. While trainees more commonly observed unprofessional behavior than safety threats, they are less likely to speak up when presented with unprofessional behavior.
Pedersen CA, Schneider PJ, Ganio MC, et al. Am J Health Syst Pharm. 2020;77(13):1026-1050.
This article describes results from the 2019 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. The authors note the increasing responsibilities placed on pharmacists and their role in addressing the opioid crisis, adopting intravenous workflow technologies, and leveraging clinical decision support tools to improve medication administration safety.
Rooney D, Barrett K, Bufford B, et al. J Patient Saf. 2020;16(3):e126-e130.
This study reviewed adverse event reporting forms from 16 dental schools and found that the forms were not standardized in structure, organization, or content. Adoption of a standardized method for event collection and assessment would allow for quality improvement and increase patient safety.
Smalley CM, Willner MA, Muir MKR, et al. Am J Emerg Med. 2020;38(8):1647-1651.
This study assessed the impact of electronic health record (EHR) interventions to standardize opioid prescribing practices across a large health system. Interventions included (1) deleting clinician preference lists, (2) default dose, frequency, and quantity, (3) standardizing formularies, and (4) dashboards with current opioid prescribing practices. In the 12 months after implementation, there was a decrease in the rate of opioid prescriptions overall, prescriptions exceeding three days, prescriptions exceeding prespecified morphine equivalent doses, and non-formulary prescriptions.

ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17).

The culture of blame is acerbated by stress, production pressure, and a negative work environment. This article discusses how medication errors that take place during the care of patients with COVID-19 are not being reported by nurses due to lack of time and psychological safety. Recommendations to avoid this situation include heightening prevention efforts by employing tactics such as deployment of huddles and use of pre-mixed medication solutions.  
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Pediatr Qual Saf. 2020;5(4):e323.
This article describes one pediatric hospital’s experience adapting and implementing the I-PASS handoff program for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff.  The project demonstrates that I-PASS can be successfully used across a hospital system in various settings to reduce handoff-related errors.  
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29(12):971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
Maurer NR, Hogan TH, Walker DM. Med Care Res Rev. 2020;Epub Aug 20.
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.