All Content

Obstetrics is a considered a high-risk care environment. This claims-based retrospective analysis found that abortion-related morbidity or adverse events occurred in nearly 4% of abortions but that event rates did not differ between OBGYNs or physicians of other specialties.

Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 

Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.

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.

England’s National Health Service (NHS) allows patients to receive care from public or for-profit private organizations. In comparing treatable mortality rates at public and for-profit providers, researchers found an additional 557 treatable deaths at for-profit private organizations between 2014 and 2020. The authors recommend further research into potential causes.

Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.

Accreditation programs are intended to improve patient safety and quality of care. Researchers in Italy aimed to develop and validate an accreditation tool for home care. The tool, validated by 21 experts, is divided into six domains: 1) Organization and governance; 2) Patient safety and risk management; 3) Professionals’ knowledge, skills, and competencies; 4) Information and communication; 5) Care integration, and 6) Improvement and innovation.

In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.

Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.

Potentially inappropriate medications (PIMs) for older adults carry a high risk of adverse drug events. Using a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state scope of practice regulations for nurse practitioners (NPs) on PIM prescribing patterns compared to primary care physicians. Findings indicate that the PIM prescribing rate is lower in states with full NP practice and lower among NPs than among physicians.

Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.