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Oregon Patient Safety Commission: 2023.
Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.
Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.
During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.1
A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
Reed J. BBC. February 27, 2023.
Farnborough, UK: Healthcare Safety Investigation Branch; February 2023.
Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.
Infect Control Hosp Epidemiol. 2022-2023.