In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.

Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.

Fragmentation of care between inpatient and outpatient settings can lead to poor patient outcomes. Based on a cohort of veterans ages 65 years or older who had a myocardial infarction, this study examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in the preceding 30 days among patients treated at Veterans Health Administration (VA) versus non-VA hospitals. The researchers found that medication omissions, duplications and delays in prescribing of secondary prevention medications were more common among patients treated at non-VA hospitals.

Ensuring medication safety in home care settings has unique challenges. In this study, researchers analyzed 1,027 incident reports involving medication errors and communication between home care and inpatient care settings. Four types of issues were identified – (1) information management such as incomplete medication lists or fragmentation of patient data, (2) cooperation between care team members, (3) work environment and lack of resources, and (4) individual-level factors, such as inadequate skills or human error.

Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.

The American Academy of Pediatrics' Policy Statement, "Preventing Home Medication Administration Errors", called for improving medication safety at home for children with medical complexity. This article describes a toolkit for pediatricians to support implementation focusing on four interventions: establishing practice-based error reporting systems, standardizing medication reconciliation, improving communication, and integrating resources for patients and families. Of particular importance is the use of health literacy-informed, culturally sensitive resources.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.

STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are used to identify potentially inappropriate prescribing in older adults. This article describes the consensus process to update and validate the third version of the STOPP/START criteria using evidence from a systematic review and input from a panel with expertise in geriatric pharmacology. The consensus process resulted in additional STOPP criteria (133 versus 80 in version 2) and START criteria (57 versus 34 in version 2). The additional criteria in version 3 can help clinicians detect and prevent adverse drug-drug and drug-disease interactions.

Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.