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Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  

The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.

Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.

Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.

Missed nursing care is recognized as an emerging patient safety issue. This study evaluated the validity and reliability of a standardized survey instrument used to detect missed nursing care and found the tool performed acceptably when used in a variety of clinical settings.

Production pressure—the pressure to continue work at maximum capacity—is a known threat to patient safety. This study analyzed the effect of production pressures by examining the relationship between two components of safety culture. Using data from the 2010 AHRQ Hospital Survey on Patient Safety Culture, the investigators found that respondents at hospitals that worked in crisis mode more frequently also were more likely to perceive care transitions as unsafe. As emergency department overcrowding has also been linked to safety issues, the results of this study argue for efforts to manage bed capacity and patient flow as a patient safety strategy. A recent AHRQ WebM&M commentary explores how communication breakdowns and production pressure can cause adverse outcomes and highlights how checklists can help prevent mistakes.

Clinical staff often fail to call rapid response teams to evaluate deteriorating patients, even when objective criteria for calling the team are met. This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture of safety can result in failure to use the rapid response team when appropriate and can also lead to using the team as a workaround to compensate for poor interdisciplinary communication.

In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.