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Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.
Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Liebowitz J. N Engl J Med. 2022;386:2456-2457.
Diagnostic errors caused by premature closure and anchoring bias occur when clinicians rely on initial diagnosis despite receiving subsequent information to the contrary. This commentary encourages clinicians to be aware of their cognitive biases during the diagnosis process.
Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.
Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
Fenton JJ, Magnan E, Tseregounis IE, et al. JAMA Netw Open. 2022;5:e2216726.
Adverse events associated with long-term opioid therapy have led to recommendations for dose tapering for patients with chronic pain. This study assessed the long-term risks of overdose and mental health crisis as a result of dose tapering. Consistent with earlier research on short-term risks, results indicate that opioid tapering is associated with increased risk of adverse events up to 24 months after initiation of tapering.
Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Rosen PD, Klenzak S, Baptista S. J Fam Pract. 2022;71:124-132.
Cognitive biases can impede decision-making and lead to poor care. This article summarizes the common types of cognitive errors and biases and highlights how cognitive biases can contribute to diagnostic errors. The authors apply these common types of errors and biases in four case examples and discuss how to mitigate these biases during the diagnostic process. 
Butler AM, Brown DS, Durkin MJ, et al. JAMA Netw Open. 2022;5:e2214153.
Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.
Prudenzi A, D. Graham C, Flaxman PE, et al. Psychol Health Med. 2022;27:1130-1143.
Previous research has found that mindfulness interventions can reduce stress and burnout among physicians. This survey of 98 healthcare workers within the UK National Health Service (NHS) explored the relationship between poor wellbeing, burnout and perceived safe practice and identified a positive relationship between mindfulness processes and perceived safe practices.
Jambon J, Choukroun C, Roux-Marson C, et al. Clin Neuropharmacol. 2022;45:65-71.
Polypharmacy in older adults is an ongoing safety concern due to the risk of being prescribed a potentially inappropriate medication or co-prescription of medications with dangerous interactions. In this study of adults aged 65 and older with chronic pain, 54% were taking at least one potentially inappropriate medication and 43% were at moderate or high risk of adverse drug events. Measures such as involvement of a pharmacist in medication review could reduce risk of adverse drug events in older adult outpatients.

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.
Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA OncolEpub 2022 Apr 21. 

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.