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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.
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. 
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.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. 

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
Sajid IM, Parkunan A, Frost K. BMJ Open Qual. 2021;10(3):e001287.
Inappropriate use or overuse of clinical tests such as MRIs can be harmful to patients. This cohort study, including 107 general practitioners across 29 practices, found that only 4.9% of musculoskeletal MRIs were clearly indicated and only 16.7% of results appeared to be correctly interpreted by clinicians, suggesting the potential for significant misdiagnosis and overdiagnosis.
Institute for Healthcare Improvement. Spring 2022.
Organization executives influence the success of patient safety improvement. This virtual workshop will meet weekly to highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77(2):899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.

Quick Safety. March 2021;58:1-2.

The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This article recommends several strategies for gaining patient trust in the system to keep them safe from exposure which include dedicated spaces for preventative services and proactive encouragement on the importance of screenings such as mammograms.

AHA Training. September 30--November 18, 2021.

Change management skills are important for leaders to implement sustainable safety improvements. This virtual 7-session workshop will use the TeamSTEPPS model to structure organizational approaches for embedding teamwork foundations into processes that support enduring improvement efforts. 
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent update documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Calcaterra SL, Lou Y, Everhart RM, et al. J Gen Intern Care. 2021;36(1):43-50.
Opioid use is an ongoing patient safety concern. This large retrospective cohort study found that patients who received oral or intravenous opioids during an urgent care visit were more likely to receive opioids at discharge, and progress to chronic opioid use
De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17(22):8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
Giap T-T-T, Park M. J Patient Saf. 2021;17(2):131-140.
Patients and families are essential partners in identifying and preventing patient safety events. This meta-analysis found that patient and family involvement interventions can significantly reduce adverse events, decrease hospital length of stay, increase patient safety experiences, and improve patient satisfaction.
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69(3):362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.
Reeves JJ, Ayers JW, Longhurst CA. J Med Internet Res. 2021;23(2):e24785.
The COVID-19 pandemic has led to an extraordinary increase in the use of telehealth. This article discusses unintended consequences of telehealth and outlines guidance to assist health care providers in determining the appropriateness of a telehealth visit.
Zhou Y, Walter FM, Singh H, et al. Cancers (Basel). 2021;13(1):156.
Delays in cancer diagnosis can lead to treatment delays and patient harm. This study linking primary care and cancer registry data found that more than one-quarter of bladder and kidney cancer patients presenting with fast-tract referral features did not achieve a timely diagnosis. These findings suggest inadequate adherence to guidelines intended to help identify patients with high risk of cancer based on the presence of alarm signs and symptoms.