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Moureaud C, Hertig JB, Dong Y, et al. Health Policy. 2021;Epub Sep 25.
Based on survey responses from 1,002 participants, this study evaluated how social media users assess, interact and engage with information related to the illegal sales of prescription medicines. Findings suggest that individuals generally perceive online pharmacies and social media platforms to be safe and respondents are confident in their ability to acquire legitimate medicines. The authors note that this false confidence has the potential to lead to patient harm given the prevalence of counterfeit and substandard medication available on these platforms.
Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40(10):1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.

Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.

Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medication safety across the spectrum of health care. The report examines the systemic and cultural issues that contribute to overprescribing and recommends a governmental leadership position to drive change and implement deprescribing and other reduction initiatives.
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30(10):804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17(7):473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33(3):mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;Epub Aug 16.
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.
Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326(5):411-419.
Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering. 
Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.
Adverse drug events are a common source of harm in both inpatient and ambulatory patients. This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical settings, and that older adults are at increased risk. Medications to treat high blood pressure and arrhythmias were the most common cause of medication harm.

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19. 

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Geneva: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2021;Epub Jul 15.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;Epub Jun 30.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Nævestad T-O, Storesund Hesjevoll I, Elvik R. Accid Anal Prev. 2021;159:106228.
Healthcare organizations are increasingly investing in promoting culture of safety to improve patient safety outcomes but few, if any, regulations exist influencing safety culture in healthcare. In a review of how regulators influence safety culture in several high-reliability fields, the authors identified six relationships between regulators and safety behavior and accidents. If healthcare regulators are to successfully influence safety culture in healthcare, attention must be paid to each relationship.
Sujan M, Habli I. BMJ Qual Saf. 2021;Epub May 27.
This commentary discusses the use of “safety cases” to communicate the safety of a product, system or service in industry (e.g., aviation, defense, railways). Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare to support the safe adoption of digital health innovations.

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summaries ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.