Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.

A clinician's knowledge of an existing condition can implicitly affect treatment recommendations and decisions. This alert highlights the presence of diagnostic overshadowing as a type of bias that is prone to affect disadvantaged or stigmatized patient populations. Listening training programs, improved use of patient data review, and assessment techniques are recommended to trigger diagnostic curiosity to encourage complete decision-making methods when serving patients.

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic. 

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.

Falls in the hospital are common, particularly among elderly patients, and falls resulting in serious injury or death are considered never events. This sentinel event alert identified 465 such cases reported to The Joint Commission since 2009 and acknowledges that preventing falls is difficult and complex. The Joint Commission recommends several strategies for preventing falls, including identifying patients at risk for falls, establishing a multidisciplinary fall prevention team, using patient-specific approaches to minimize fall risk, and conducting a post-fall multidisciplinary huddle to detect system flaws. These strategies have been successfully applied and shown to reduce falls in high-quality studies. The role of the physical environment as a risk for falls and the use of post-fall huddles are discussed in a recent AHRQ WebM&M commentary.

The introduction of information technology (IT) has transformed health care, but it is clear that the rapid uptake of IT has profoundly changed clinician workflow, resulting in unintended consequences that in some cases have harmed rather than helped patients. These unintended consequences include new types of errors resulting from computerized provider order entry, alarm fatigue arising from the proliferation of well-intended safety alerts, and problems with poor interoperability of different electronic medical record systems. The Joint Commission issues sentinel event alerts periodically to highlight emergent safety issues, and this alert describes some of the 120 sentinel events reported to The Joint Commission since 2003 that were determined to be related to IT. Several recommendations to prevent IT–related safety threats are discussed, including improving safety culture by creating a shared sense of responsibility between users and developers, paying careful attention to safe IT implementation, and engaging leadership to provide oversight in health IT planning, implementation, and evaluation. The hazards and benefits of health IT are the subject of a recent book by a prominent patient safety expert.

The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.