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1 - 20 of 128
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.

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms. 

MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.
Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

ISMP Medication Safety Alert! Acute care edition. February 10, 2022:27(3):1-6.

Best practices evolve over time, given experience and evidence associated with their use. This article summarizes 3 new areas of focus included in current recommendations for sustaining medication safety. The new practices focus on improving the safety of oxytocin use, enhancing vaccine administration through bar coding, and implementing multifocal efforts to reduce high-alert medication errors. A survey accompanies the article to gather data on the presence of the new recommendations in the field. 
Sullivant SA, Brookstein D, Camerer M, et al. Jt Comm J Qual Patient Saf. 2021;47:496-502.
Improving screening for suicidal ideation is an important patient safety priority. This article describes the implementation and evaluation of a hospital-wide program to identify teenagers at elevated risk for suicide and to connect them with services. During the first year of implementation, over 138,000 screenings were completed and 6.8% of screens were positive for elevated risk.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.

Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff.  This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.  
Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2021;61:e46-e52.
This article describes a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.
Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146: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%.
Choi GYS, Wan WTP, Chan AKM, et al. Br J Anaesth. 2020;125:e236-e239.
This study used high-fidelity clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known COVID-19 infection to assess the ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation protocols and infection control guidelines. Based on observations of 11 simulations involving 44 participants, several infection control-related workflow problems and safety threats were identified, including issues with PPE donning and doffing, advance preparation of intubation and ventilation strategies, environmental protection measures, communication difficulties, and accessibility of key drugs and equipment. These findings resulted in guideline changes, modifications to the environment and implementation of workflow modifications to improve ability of staff to adhere to infection control guidelines.
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
Malterud K, Aamland A, Fosse A. Scand J Prim Health Care. 2020;38.
Using qualitative analysis, this study explored the experiences of general practitioners in Norway with horizontal task shifting (defined as tasks shifted between equivalent professionals, such as hospital specialists and other specialists) and whether task shifting increased patient safety risks. The study identified several types of adverse events associated with horizontal task shifting, such as delays in diagnosis, overdiagnosis, and reduced access to care.
Dexter F, Parra MC, Brown JR, et al. Anesth Analg. 2020;131:37-42.
The authors describe eight empirical recommendations for optimizing infection control and operating room (OR) management during the COVID-19 pandemic. Recommendations address (1) hand hygiene, (2) environmental cleaning, (3) patient decolonization, (4) vascular care, (5) surveillance of pathogen transmission, (6) efficient use of personal protective equipment (7) OR scheduling, and (8) postoperative recovery settings.