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Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156(1):76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   
Haydar B, Baetzel A, Stewart M, et al. Anesth Analg. 2020;131(1):245-254.
Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2020;76(2):230-240.
This study assessed the performance of an automated emergency department (ED) trigger tool designed to identify a more efficient sample of adverse event cases for chart review. Beginning with a set of 97 candidate triggers, researchers identified those triggers associated with adverse events and arrived at a narrowed set of 30 triggers, eliminating almost half of the population of records eligible for manual review. This computerized query may eliminate the need for manual screening for triggers.  
Smalley CM, Willner MA, Muir MKR, et al. Am J Emerg Med. 2020;38(8):1647-1651.
This study assessed the impact of electronic health record (EHR) interventions to standardize opioid prescribing practices across a large health system. Interventions included (1) deleting clinician preference lists, (2) default dose, frequency, and quantity, (3) standardizing formularies, and (4) dashboards with current opioid prescribing practices. In the 12 months after implementation, there was a decrease in the rate of opioid prescriptions overall, prescriptions exceeding three days, prescriptions exceeding prespecified morphine equivalent doses, and non-formulary prescriptions.
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38(6):1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8(8):639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.    
Feeser VR, Jackson AK, Savage NM, et al. Ann Emerg Med. 2021;77(4):449-458.
This study characterized patient safety event report submissions over a six-month period at one university health system and found that one-quarter of reports were punitive. Compared to nonpunitive reports, punitive reports were more likely to focus on communication and employee behavior issues, policies/procedures, and staff training or competency issues. Punitive reports commonly involved adverse reactions or complications and communication errors.  
Stulberg JJ, Huang R, Kreutzer L, et al. JAMA Surg. 2020;Epub Aug 19.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Vandenberg AE, Kegler M, Hastings SN, et al. Int J Qual Health Care. 2020;32(7):470-476.
This article describes the implementation of the Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) medication safety program at three academic medical centers. EQUIPPED is a multicomponent intervention intended to reduce potentially inappropriate prescribing among adults aged 65 and older who are discharged from the Emergency Department. The authors discuss lessons learned and provide insight which can inform implementation strategies at other institutions.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131(4):1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  
Engelhardt KE, Bilimoria KY, Johnson JK, et al. JAMA Surg. 2020;155(9):851-859.
This mixed-methods study analyzed data from a survey of general surgery residents and qualitative interviews with residents and program directors participating in the FIRST trial to assess preparedness for surgical residents. Results indicate the lack of preparedness was associated with inadequate exposure to resident responsibilities while in medical school, such as infrequent overnight calls or not completing a subinternship. Preparedness was associated with a nearly two-fold lower risk of experiencing burnout.
Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304(11):1198-1203.
Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.