Horsham, PA; Institute for Safe Medication Practices: February 2019.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Kang H, Wang J, Yao B, et al. JAMIA Open. 2018;2(1):179-186.
Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154(1):e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13(1):98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Bohnert ASB, Guy GP, Losby JL. Ann Intern Med. 2018;169(6):367-375.
The opioid epidemic continues to be a pressing patient safety challenge in the United States. Many efforts have been implemented to curb opioid prescribing, such as policy initiatives and targeted feedback to individual clinicians. A major initiative was the release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for patients with chronic pain. These guidelines (which do not apply to patients with cancer or patients receiving palliative care) called for initially using nonopioid medications and nonpharmacologic approaches to chronic pain before using opioids, prescribing immediate-release instead of long-acting medications, and avoiding use of other sedating medications. This study examined trends in opioid prescribing rates before and after the CDC guidelines were released. Investigators found that opioid prescribing overall has decreased between 2012 and 2017, but the rate of decline increased after dissemination of the CDC guidelines. Perhaps the most notable finding is that the number of high-dose opioid prescriptions declined by nearly 50% over the study period (from 683 to 356 prescriptions per 100,000 adults). An Annual Perspective discussed the causes and potential solutions to opioid overprescribing.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27(12):954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28(1):74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Machine learning, a type of computing that uses data and statistical methods to enable computers to progressively enhance their prediction or task performance over time, has been widely promoted as a tool to improve health care safety. This commentary describes the potential for machine learning to worsen socioeconomic disparities in health care. Disadvantaged populations are more likely to receive care in multiple health systems. Therefore, relevant data about their health may be missing in an individual health system's records, hindering performance of machine learning algorithms. Racial and ethnic minority patients may not be present in sufficient numbers for accurate prediction. The authors raise concern that implicit bias in the care that disadvantaged populations receive may influence algorithms, which will amplify this bias. They recommend inclusion of sociodemographic characteristics into algorithms, building and testing algorithms in diverse health care systems, and conducting follow-up testing to ensure that machine learning does not perpetuate or exacerbate health care disparities.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27(12):1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018;93:1571-1580.
Physician burnout is a highly prevalent patient safety concern. Researchers employed data from the American Medical Association to survey United States physicians about burnout and safety. Of 6586 respondents, 54% reported burnout symptoms, consistent with prior studies. More than 10% of respondents reported a major medical error in the prior 3 months, and these rates were even higher among physicians that had symptoms of burnout, even after adjustment for personal and practice factors. The majority of physicians graded their work unit safety as excellent or very good. The authors conclude interventions to improve safety must address both burnout and work unit safety. Because the survey response rate was less than 20%, it is unclear whether these findings reflect practicing US physicians more broadly. An Annual Perspective summarized the relationship between clinician burnout and patient safety.
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. BMJ Qual Saf. 2019;28(1):39-48.
This study developed a measure of patient safety leadership style for nurse managers. Researchers found that their measure of control-based versus commitment-based safety management was valid and reliable after testing among clinical nurses.
World Health Organization; Organisation for Economic Co-operation and Development; OECD; World Bank.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Gomes T, Tadrous M, Mamdani MM, et al. JAMA Netw Open. 2018;1(2):e180217.
Opioid use can increase risk of adverse drug events, including overdoses. Researchers utilized data from the Centers for Disease Control and Prevention to examine opioid-related deaths in the United States from 2001 to 2016. During this period, opioid-related deaths increased by nearly 350%. Overdose deaths occurred more among men than women and were most prevalent in patients aged 15 to 34 years. These findings raise concern regarding the increasing proportion of deaths associated with opioid use. The authors call for targeted prevention and harm reduction efforts among young adults to address the growing opioid-related harm in this group. A PSNet perspective discussed opioid overdose as a patient safety problem.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74(7):1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Larochelle MR, Bernson D, Land T, et al. Ann Intern Med. 2018;169(3):137-145.
Nationally, opioid overdose remains a common cause of preventable death. Treatment of opioid use disorder with opioid replacement therapy, specifically methadone or buprenorphine, is a potent but underutilized strategy for reducing opioid-related harm. Investigators employed a prospective cohort study to follow 17,568 adults who were treated in Massachusetts emergency departments for a nonfatal opioid overdose. About 15% received opioid replacement therapy in the subsequent 2 years. Patients on opioid replacement therapy were substantially less likely to die from opioids or any other cause. An accompanying editorial from leaders at the National Institute on Drug Abuse highlights strategies to increase the number of Americans offered these life-saving therapies. The editorial also notes the alarming number of patients who received prescriptions for short-acting opioids and benzodiazepines after an opioid overdose. A past Annual Perspective and PSNet perspective delineated other strategies for addressing the opioid crisis.
Rosen MA, DiazGranados D, Dietz AS, et al. Am Psychol. 2018;73(4):433-450.
Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37(6):964-974.
The opioid epidemic is a well-recognized national patient safety issue. High-risk opioid prescribing can contribute to misuse. Provider prescribing has come under increased scrutiny and several states have implemented prescription drug monitoring programs (PDMPs). Prior research suggests that such programs have the potential to reduce opioid-related harm. This study used commercial claims data to assess the impact of PDMPs implemented in four states in 2012–2013 on opioid prescribing. By the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of morphine-equivalents prescribed per person per quarter compared with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid prescription. The authors conclude that PDMPs have the potential to reduce opioid use and improve prescribing practices. An Annual Perspective highlighted safety issues associated with opioid medications.
Opioids are known to be high-risk medications. This secondary data analysis of more than 100,000 patients undergoing in-hospital surgical procedures at 21 hospitals found that about 10% experienced an opioid-related adverse drug event during their admission. Patients receiving higher dose and longer duration of opioids were more likely to experience adverse events. Patients who experienced an opioid-related adverse drug event had longer hospital stays, greater inpatient mortality risk, and a higher rate of readmissions compared to those who did not experience problems with opioid medications. The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient safety. A previous WebM&M commentary emphasized the importance of stratifying risk for patients initiated or maintained on chronic opioid therapy to prevent misuse.
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