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Kepner S, Jones RM. Patient Safety. 2022;4:18-33.
Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.

Whitaker B. CBS News. May 22, 2022.

Drug shortages represent a complex system level challenge in health care that can harm patients. This news segment details economic and production factors that affect the availability of generic medications. Clinicians and families were interviewed to share tactics for managing these situations to support patient safety despite shortages.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.

Am J Health Syst Pharm. 2022;79(7): 564-599.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.
McGinty EE, Bicket MC, Seewald NJ, et al. Ann Intern Med. 2022;175:617-627.
Prior research has found that unsafe opioid prescribing practices are common. This retrospective study explored the association between state opioid prescribing laws and trends in opioid and nonopioid pain treatment among commercially insured adults in the United States. Findings suggest that these laws were not associated with statistically significant changes in prescribing outcomes, but the authors note that some of these estimates were imprecise and may not be generalizable to non-commercially insured populations.
Moureaud C, Hertig JB, Dong Y, et al. Health Policy (New York). 2021;125:1421-1429.
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.
Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4:e2125173.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.

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.

Szalavitz M. Wired Magazine. August 11, 2021. 

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.
Osborne V. Curr Opin Psychiatry. 2021;34:357-362.
The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.
Reynolds KA, Hellquist K, Ibrahim SA, et al. Arch Dermatol Res. 2022;314:363-367.
Adverse events associated with pharmacy compounding (e.g., parenteral nutrition, sterile compounding) are well-documented. This survey of state medical and osteopathic boards gathered information about compounding-associated adverse events in physician offices and use of compounding standards. Findings indicate that the incidence of in-office compounding-related adverse events is low and that the majority of respondents had not incorporated compounding standards into their regulations.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4:e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.  
Piatek OI, Ning JC-min, Touchette DR. Am J Health Syst Pharm. 2020;7:1778-1785.
Drug shortages are an ongoing threat to safe patient care. This commentary discusses the impact of COVID-19 on medication supply and demand, and the resulting drug shortages. The authors provide several recommendations for reducing future drug shortages in times of crises, including increasing stockpiles and creating a critical drug list with potential substitutes.
Reiner G, Pierce SL, Flynn J. J Am Pharm Assoc (2003). 2020;60(5):e50-e56.
Despite prevention efforts, medication administration errors continue to pose threats to patient safety. This study used malpractice claims data to explore trends in wrong drug and wrong dose dispensing errors. Between 2013 and 2018, the percentage of claims associated with both wrong drug and wrong dose dispensing errors decreased, but these errors were still involved in a considerable percentage of cases (36.8% and 15.3% of cases, respectively).

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.
Classen DC, Holmgren AJ, Co Z, et al. JAMA Netw Open. 2020;3.
Researchers measured the safety performance of electronic health record (EHR) systems using simulated medication orders that can lead to adverse events or death in order to evaluate how well the systems identified these errors, and the mitigating effect of computerized physician order entry and clinical decision support (CDS) tools. Safety performance increased moderately over the 10-year study period but there was considerable variation in performance based on the level of decision support (basic or more complex) and EHR vendor; safety risks persist despite EHR implementation.