Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.

In this cross-sectional study, researchers evaluated medication safety letters issued by Health Canada, the United States Food and Drug Administration, and the United Kingdom Medicines and Healthcare products Regulatory Agency over a 4-year period to evaluate consistency of structure and content as well as timing and commonality of subject matter. They found significant differences in the medication safety letters issued by all three agencies with regard to both the timing and the focus. The authors suggest that better coordination across these bodies might improve patient safety.

According to this study, many adverse drug event reports submitted by drug manufacturers to the Food and Drug Administration were incomplete. The authors advocate for the FDA to update their reporting requirements and compliance policies.

… patient information. A prior AHRQ WebM&M interview with Michael Cohen, president of ISMP, discussed medication safety. …

Sociotechnical probabilistic risk assessment—a prospective method of identifying potential patient safety hazards—was used to assess the risk for medication errors in community pharmacies.

This commentary discusses the importance of handoff communication in ensuring safe transfers and recommends that mental models be developed within the care team to improve handoff safety.

… care leaders to prevent harm. … Federico FA, Benjamin B, Cohen M. Healthc Exec. 2011;26:80-83.   …

This report discusses examples of serious medication errors involving "sound-alike" drugs as well as use of ambiguous abbreviations.

This review highlights gaps in the current literature on handoffs, which include inadequate research supporting best practices in the context of growing mandates to do so.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.

This monthly article discusses incidents involving dosing errors and describes strategies to promote the safe use of oral syringes.

Voluntarily reported adverse drug events increased markedly from 1998-2005, with a small proportion of drugs accounting for a disproportionate share of adverse events.

… Jt Comm J Qual Patient Saf … This survey, conducted by the  Institute …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The authors review selected incidents of …

… Jt Comm J Qual Saf … Jt Comm J Qual Patient Saf … This article reports the results of the …