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Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;Epub May 20.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Petersen C, Smith J, Freimuth RR, et al. J Amer Med Inform Assoc. 2020;28(4):677-684.
Clinical decision support (CDS) systems are intended to support diagnosis and therapeutic processes of care. This position paper defines adaptive CDS as “systems that can learn and change performance over time, incorporate new clinical evidence, data types, data sources, and methods for interpreting data.” Recommendations for the effective management and monitoring of adaptive CDS are outlined.

The team at Geisinger sought to develop an outpatient addiction medicine specialty program that incorporated medication-assisted treatment (MAT), peer support, and connection to community counseling services that also uses data-driven insights to monitor and improve patient outcomes. As a result of this program, they have been able to reduce all-cause mortality among these patients, increase patient engagement in substance use disorder treatment, and have seen a reduction in the prescription quantities of controlled substances.

Berg TA, Hebert SH, Chyka D, et al. Simul Healthc. 2020;Epub Dec 5.
Nurses are often responsible for medication administration at the bedside. This simulation study found that a smart phone app providing just-in-time medication administration information could reduce the occurrence of medication administration errors by nursing students. 

Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.   

Patient misidentification errors have the potential for serious patient harm. This study analyzed the processes of care involved in 1,189 wrong-patient events. Most errors occurred during ordering/prescribing (42%). One-quarter of all events reached the patient, most commonly involving inappropriate medication administration or receiving the wrong test or procedure. Errors caught before reaching the patient were primarily attributed to information review by nurses, technicians, or other healthcare staff. The authors recommend several strategies for reducing wrong-patient errors. 
Wiley KK, Hilts KE, Ancker JS, et al. JAMIA Open. 2020;Epub Nov 29.
Optimal use of health information exchange approaches such as event notification systems may be influenced by organizational capabilities. This study found that healthcare organizations whose positive perceptions of event alerts fit within existing workflows were more likely to use event notification services to improve care coordination and care quality.
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27(8):1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  
Fearon NJ, Benfante N, Assel M, et al. Jt Comm J Qual Patient Saf. 2020;46(7):410-416.
Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.

David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and content expert for artificial intelligence in medical imaging. We spoke with him about the role artificial intelligence can play in healthcare diagnostics and the potential for reducing diagnostic errors.

Feldman SS, Brazil V, Zengul FD, et al, eds. Health Syst (Basingstoke). 2019;8(3):153-227.
Informatics and simulation are core contributors to the reduction of medical system failures. This special issue examined how these ideas merge to create opportunities for improvement. Care management and adverse incident prevention are two areas of focus explored in the issue.   
Bourgeois FC, Fossa A, Gerard M, et al. J Am Med Inform Assoc. 2019;26:1566-1573.
OpenNotes enables patients and their designated caregivers to access medical records and provider documentation. Research has shown that this access may have the potential to improve medication adherence and patient engagement, and that patients may be able to identify errors in documentation. In this study performed at three distinct medical centers, researchers evaluated the effects of implementing a system for patients and families to report mistakes they saw in outpatient documentation. Of the 1440 reports obtained, 27% suggested possible inaccuracies and frequently prompted a change in the medical record. Symptom descriptions, past medical history, and medications were most commonly identified as areas of potential discrepancy by patients and families. An Annual Perspective discussed mechanisms for engaging patients as partners in safety.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Elger BM, Esparaz JR, Nierstedt RT, et al. Journal of Pediatric Surgery. 2020;55.
Prior research has shown that engaging parents in promoting the surgical safety of pediatric patients is viewed positively by both parents and staff. In this study, researchers assessed the impact of a digital application, SafeStart, on parental engagement in surgical safety. The application was presented to parents via tablet and required parents to verify safety information for their child throughout the surgical process. They found that use of the application improved parents' knowledge of surgical safety and that parents preferred it to standard surgical consent processes.
Rupp MT. Journal of the American Pharmacists Association : JAPhA. 2019;59:474-478.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the workload and ineffective computer systems. This commentary explores how to enhance the safety of community pharmacy practice and recommends improvements in reimbursement, quality metrics, training, electronic information tools, and staffing to achieve safe medication use at the community level.
Holmgren J, Co Z, Newmark L, et al. BMJ quality & safety. 2020;29:52-59.
A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.
de Araújo BC, de Melo RC, de Bortoli MC, et al. Front Pharmacol. 2019;10:439.
Prescribing errors are common and can result in patient harm. This review summarizes four key options to reduce prescribing errors: prescriber education, effective use of computerized alert systems at the clinical interface, use of tools and guidance to inform practice, and multidisciplinary teams that include pharmacists.

Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
Van de Vreede M, McGrath A, de Clifford J. Aust Health Rev. 2018;43(3):276-283.
This retrospective study of voluntary safety reports examined medication errors related to electronic prescribing. Researchers found that errors related to electronic prescriptions accounted for a small proportion of medication errors and were of low severity. They suggest that safety monitoring and feedback continue to be needed for electronic prescribing.
Dick V, Sinz C, Mittlböck M, et al. JAMA dermatology. 2019.
Advanced computing holds promise for reducing missed diagnoses of cancer. This metanalysis found that computer-aided diagnosis effectively detects melanoma; however, studies were low in quality. The authors suggest that these systems may help assist dermatologists in overcoming the limitations of human cognition for performing repetitive tasks.