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Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;Epub Apr 7.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels. 
Virnes R-E, Tiihonen M, Karttunen N, et al. Drugs Aging. 2022;39:199-207.
Preventing falls is an ongoing patient safety priority. This article summarizes the relationship between prescription opioids and risk of falls among older adults, and provides recommendations around opioid prescribing and deprescribing.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259

Nursing homes face significant patient safety challenges, and these challenges became more apparent during the COVID-19 pandemic. This report identifies key issues in the delivery of care for nursing home residents and provides recommendations to strengthen the quality and safety of care delivery, such as improved working conditions, enhanced minimum staffing standards, improving quality measurement, and strengthening emergency preparedness.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.

Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.
Damoiseaux-Volman BA, Raven K, Sent D, et al. Age Ageing. 2022;51:afab205.
According to an Agency for Healthcare Research and Quality study, an estimated 700,000 to 1 million hospitalized patients fall each year. This study assessed the impact of potentially inappropriate medications (PIM) on falls in older adults and compared the impact of three deprescribing tools on inpatient falls. PIMs identified by section K of the Screening Tool of Older Persons' Prescriptions (STOPP) had the strongest association with inpatient falls.
Patel TK, Patel PB, Bhalla HL, et al. Eur J Clin Pharmacol. 2022;78:267-278.
Adverse drug events are common and often result in preventable patient harm. Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related deaths contributed to 5.6% of all inpatient hospital deaths. The authors estimated that almost half of drug-related deaths are preventable.
Mimmo L, Harrison R, Travaglia J, et al. Dev Med Child Neurol. 2022;64:314-322.
Children with intellectual disabilities may experience poor-quality care and be at higher risk for patient safety events. This cross-sectional study including patients admitted to two children’s hospitals in Australia found that children with intellectual disabilities had longer hospital stays and experienced more admissions with at least one clinical incident (e.g., medication incidents, documentation errors) compared to children without intellectual disabilities.
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
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.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;Epub Jan 28.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2021;Epub Nov 30.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;17:e1285-e1295.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.