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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.
Halverson CC, Scott Tilley D. Nurs Forum. 2022;57:454-460.
Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.

The APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.
Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.
The CancelRx system is a health information technology-based intervention intended to mitigate the challenges of communicating medication discontinuation. Using secondary data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that implementing the CancelRx system resulted in a significant increase in successful medication discontinuations for controlled substances.
Koeck JA, Young NJ, Kontny U, et al. Front Pediatr. 2021;9:633064.
Medication safety in children is a patient safety priority. This systematic review explored interventions to reduce medication dispensing, administration, and monitoring errors in pediatric healthcare settings. The majority of identified studies used “administrative controls” to prevent errors, but those implementing higher-level interventions (such as smart pumps and mandatory barcode scanning) were more likely to result in error reduction.
Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20:506.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.  
Hodkinson A, Tyler N, Ashcroft DM, et al. BMC Med. 2020;18:313.
Medication errors represent a significant source of preventable harm. This large meta-analysis, including 81 studies, found that approximately 1 in 30 patients is exposed to preventable medication harm, and more than one-quarter of this harm is considered severe or life-threatening. Preventable medication harm occurred most frequently during medication prescribing and monitoring. The highest rates of preventable medication harm were seen in elderly patient care settings, intensive care, highly specialized or surgical care, and emergency medicine.
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24:1-6.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Metersky ML, Eldridge N, Wang Y, et al. J Hosp Med. 2016;11:276-82.
Anticoagulation medications are often associated with adverse drug events. This study found that less-than-daily monitoring of anticoagulation in hospitalized patients is associated with more frequent out-of-range values, suggesting that daily monitoring is safer.
Goldberg A, Silverman E, Samuelson S, et al. Br J Anaesth. 2015;114:794-800.
Simulation training has been increasingly adopted as a valuable teaching tool, particularly for surgeons and anesthesiologists. This study found that allowing first-year anesthesia residents to independently fail at a scenario, causing simulated morbidity or mortality, resulted in better performance on a different, but similar, scenario 6 months later.
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.
Kaushal R, Kern LM, Barrón Y, et al. J Gen Intern Med. 2010;25.
Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.