A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4:e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.
Osmundson SS, Min JY, Wiese AD, et al. Ann Intern Med. 2020:Epub Jun 9.
This study prospectively followed 161,318 women who were discharged after childbirth between January 2007 and August 2014 to assess the risk of serious opioid-related events after vaginal and cesarean births. Both vaginal births (59%) and cesarean births (91%) involved one or more filled opioid prescription. Serious opioid-related events were 1.4- and 3.6-times more likely to occur among women filling one or two prescriptions compared to women who did not fill any opioid prescription after childbirth. Reducing opioid prescribing after childbirth may decrease the incidence of future serious opioid-related events.
Chidgey BA, McGinigle KL, McNaull PP. JAMA Surg. 2019;154:987-988.
This commentary discusses how regulation, misinformation, and cultural beliefs influenced opioid prescribing behaviors for pain management that contributed to the opioid crisis. The author reviews efforts to address the problem, including a comprehensive approach to promote the use of nonopioid analgesics in perioperative care.
Litman RS. J Patient Saf Risk Manag. 2019;24:158-165.
This commentary explores how gaps in legal and regulatory structure affect anesthesia medication safety. The author advocates for use of a public health law framework to prevent certain types of perioperative medication errors made by anesthesiologists. Policy approaches that require organizations to provide prefilled syringes and barcoding scanners are suggested to avoid vial- and syringe-related mistakes.
Habbouche J, Lee J, Steiger R, et al. JAMA Surg. 2018;153:1111-1119.
Various regulatory and policy initiatives are being implemented to encourage more responsible opioid prescribing in the face of the ongoing opioid epidemic. One such federal initiative, implemented by the Drug Enforcement Agency in 2014, was to change hydrocodone to a schedule II agent, which restricted hydrocodone to a 90-day supply that could not be prescribed or refilled by telephone. This study examined the effect of the change on hydrocodone prescribing for patients in Michigan who had undergone elective surgery, using a database that measured opioid prescriptions filled by patients. Implementation of the new regulation was associated with an unexpected increase in the amount of opioids filled initially after surgery. Although prescription refill rates decreased, overall there was no significant difference in the total amount of opioids prescribed within the 30-day postoperative period after the schedule change was implemented. The authors hypothesize that the increased restrictions on hydrocodone prescribing may have resulted in surgeons giving larger initial prescriptions in order to ensure postoperative pain control. The effect of national regulatory initiatives on opioid prescribing remains unclear at present, but recent studies have shown that personalized feedback to prescribers may be effective at improving prescribing.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Benjamin L, Frush K, Shaw K, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Hampton LM, Nguyen DB, Edwards JR, et al. Pediatrics. 2013;132:1047-54.
Emergency department visits for cold and cough medication–related adverse events among children younger than 3 years declined significantly following manufacturers' voluntary withdrawal from the market and label revisions.
Naessens JM, Campbell CR, Shah N, et al. Am J Med Qual. 2012;27:48-57.
The epidemiology of adverse events on a population basis has been well studied, but how these data translate to risks for individual patients is not as clear. The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this study sought to evaluate a complementary question: whether patients who are more severely ill at admission are at increased risk of preventable harm. By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error reports, and infection control reports—to clinical databases, the authors were able to show that higher illness severity is associated with an increased risk of adverse events during hospitalization. These findings are supported by the fact that intensive care unit patients have consistently been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient with multiple underlying comorbidities.
This study analyzed nearly a hundred claims alleging patient harm and categorized them by error type, with the most frequent being drug administration errors. Investigators surmised that less than half the claims could have been prevented by using recommended double checking processes.
Intensive care units with a higher proportion of certified registered nurses had lower rates of certain patient safety outcomes, including incidence of falls. Greater nursing experience also was correlated with lower rates of medication errors.
Long A-J, Chang P, Li Y-C, et al. Int J Med Inform. 2008;77.
This study used a log file within a computerized physician order entry (CPOE) system to understand the role physician- and policy-related variables, as well as patient resistance, played in responding to electronic reminders about drug duplication orders.
Wachter RM, Flanders SA, Fee C, et al. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
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