Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.

Opioid pain medications carry high risk for adverse drug events, and opioid misuse is a growing patient safety concern. This guideline provides recommendations to augment safe prescribing of these high-risk medications for patients with chronic noncancer pain.

Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.

This guideline reviews recommendations and best-practice statements from an international consensus committee on sepsis treatment and management to guide safe care for patients with sepsis or septic shock.

Most research has focused on developing and implementing checklists in surgical settings. This guideline recommends a set of pre-procedure checklist items and offers rationales for each to help hospitals develop a checklist for use in interventional radiology.

This guideline reports on recommendations from an expert panel to prevent bile duct injuries during laparoscopic cholecystectomy, despite limited evidence on this rare complication.

This article discusses strategies to prevent catheter-related infections.

Falls are a major source of preventable morbidity and mortality for elderly patients in both the ambulatory care and hospital setting. However, efforts to prevent falls have been limited by a lack of high quality evidence supporting specific prevention strategies. This AHRQ-funded systematic review identified several focused interventions, including physical therapy, exercise, and vitamin D supplementation, that appeared to reduce the risk of falls in outpatients. The evidence base in this area has also been strengthened by recent studies showing that patient education and individualized interventions can prevent falls in hospitalized patients.

Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.

This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.

The authors provide guidelines to help manage risks and ensure the safe administration of oral anticoagulant therapy in the United Kingdom.

The investigators used existing data and guidelines to develop this standard operating procedure for the diagnosis and treatment of ventilator-associated pneumonia.

This clinical guideline on minimizing intraoperative awareness through appropriate monitoring has been approved as a standard by the American Society of Anesthesiologists. They have crafted a patient advisory to inform consumers on the issue.

To proactively devise a patient safety strategy for anesthesia, the authors of this article summarized a series of mandatory standards implemented at Boston’s nine component teaching hospitals. The authors discuss the detailed process that led to the highlighted standards, including the need to balance physician autonomy with the larger goal of improving patient care. One of the objectives from their efforts was to demonstrate the applicability of the process and to counter increases in anesthesia-related malpractice claims. They suggest the need for both a strong commitment to leadership and the development of a process to foster similar standards and improvements throughout the country.

This article describes information about surgical fires, including instigating factors and prevention strategies for all team members.