The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Dowell D, Haegerich T, Chou R. N Engl J Med. 2019;380:2285-2287.
Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.
Rajkomar A, Dean J, Kohane I. New Engl J Med. 2019;380:1347-1358.
Machine learning in health care is in the early stage of application. This review explores machine learning and its potential to enhance clinical decision-making as a tool for safe value-based care. The authors discuss how machine learning can affect prognosis, diagnosis, treatment, clinician workflow, and access to expertise. They describe key challenges to integrating machine learning in health care, including access to high-quality data.
Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Jackson D, Sarki AM, Betteridge R, et al. Int J Nurs Stud. 2019;92:109-120.
Hospital-acquired pressure ulcers are considered never events and represent a significant source of patient harm. This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related to the use of medical devices.
Rhee C, Jones TM, Hamad Y, et al. JAMA Netw Open. 2019;2:e187571.
The degree to which sepsis contributes to inpatient mortality and the extent to which sepsis-associated inpatient mortality is preventable remains unknown. In this retrospective cohort study, researchers analyzed the medical records of 568 adult patients hospitalized at 6 United States hospitals who either died during the hospitalization or were discharged to hospice. They found a diagnosis of sepsis was present in 300 cases and that it was the main cause of death in 198 cases. Reviewers rated 11 of the 300 sepsis-associated deaths as definitely or moderately likely preventable. The authors conclude that it may be challenging to further reduce sepsis-associated inpatient mortality.
Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.
Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.
Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.
Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. JAMA Netw Open. 2019;2:e186007.
Reducing opioid-related overdoses and deaths is a national patient safety priority. Little is known as to the extent to which direct-to-provider marketing of opioids by pharmaceutical companies influences physician prescribing and patient mortality related to overdose from prescription opioids. In this study, researchers analyzed data from both the Centers for Medicare and Medicaid Services Open Payments database and the Centers for Disease Control and Prevention on opioid prescribing and fatal overdoses at the county level within the United States from August 2014 through December 2016. They linked this to pharmaceutical company marketing data from August 2013 to December 2015. Using the Open Payments database, they found that there were 434,754 payments related to opioid marketing made to 67,507 providers across 2,208 counties accounting for almost $40 million. Further analysis revealed that marketing to providers was associated with increased prescribing of opioids and mortality from opioid overdoses. An accompany commentary concludes that numerous approaches will be necessary to effectively mitigate the opioid epidemic.
Reeve E, Wolff JL, Skehan M, et al. JAMA Intern Med. 2018;178:1673-1680.
Deprescribing or stopping unnecessary medications is an important strategy for reducing medication-related harm in older adults. A group of 1981 Medicare beneficiaries reported broad support (92%) for stopping at least one of their medications if their clinician determined it was safe. A WebM&M commentary provides in-depth recommendations to achieve safe prescribing in older patients.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154:e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
Shortliffe EH, Sepúlveda MJ. JAMA. 2018;320:2199-2200.
Clinical decision support on the front line of care harbors both potential benefits and barriers to effective care delivery. This commentary outlines system challenges such as complexity and poor communication that hinder reliable adoption and use of clinical decision support. The authors highlight the need for research and evaluation models to help bring clinical decision support safely and effectively into daily health care work.
Magill SS, O'Leary E, Janelle SJ, et al. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13:98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Bates DW, Singh H. Health Aff (Millwood). 2018;37:1736-1743.
The release of the Institute of Medicine's To Err Is Human in 1999 represented a seminal moment in patient safety and is considered by many to have launched the modern patient safety movement. The report highlighted the incidence of medical errors and preventable deaths in the United States and catalyzed research to identify interventions for improvement. The authors reflect on progress since its publication and suggest that while many effective interventions have been developed for addressing safety challenges such as hospital-acquired infections and medication errors, successful implementation of these solutions remains difficult, and improvement in other areas has been less consistent. In addition, new safety challenges have emerged in the last 20 years including those related to ambulatory care and diagnostic error. The authors conclude that preventable harm remains significant and advocate for enhanced use of widely available electronic data to develop improved interventions for what they foresee may be a Golden Era of swift progress in patient safety. A PSNet perspective reflected on patient safety progress in surgery.
The Moore Foundation provides free access to this article.
Dyrbye LN, Burke SE, Hardeman RR, et al. JAMA. 2018;320:1114-1130.
Physician burnout threatens the well-being and sustainability of the health care workforce. This large prospective cohort study found that 45% of resident physicians experienced burnout. Higher burnout rates were detected in urology, general surgery, emergency medicine, and neurology residents (relative to internal medicine residents). The overall prevalence of burnout was similar to studies of practicing physicians, and significantly higher than studies of the general population. Although most residents were satisfied with their career choice, those who were burned out were more likely to regret their decision to become a physician. An Annual Perspective explored how burnout impacts patient safety.
Bohnert ASB, Guy GP, Losby JL. Ann Intern Med. 2018;169:367-375.
The opioid epidemic continues to be a pressing patient safety challenge in the United States. Many efforts have been implemented to curb opioid prescribing, such as policy initiatives and targeted feedback to individual clinicians. A major initiative was the release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for patients with chronic pain. These guidelines (which do not apply to patients with cancer or patients receiving palliative care) called for initially using nonopioid medications and nonpharmacologic approaches to chronic pain before using opioids, prescribing immediate-release instead of long-acting medications, and avoiding use of other sedating medications. This study examined trends in opioid prescribing rates before and after the CDC guidelines were released. Investigators found that opioid prescribing overall has decreased between 2012 and 2017, but the rate of decline increased after dissemination of the CDC guidelines. Perhaps the most notable finding is that the number of high-dose opioid prescriptions declined by nearly 50% over the study period (from 683 to 356 prescriptions per 100,000 adults). An Annual Perspective discussed the causes and potential solutions to opioid overprescribing.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
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