The PSNet Collection

Medication safety issues with newly authorized PAXLOVID.

Save to Library

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

Input for the TeamSTEPPS Curriculum Updates.

Save to Library

Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum.

Age-related COVID-19 vaccine mix-ups.

Save to Library

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Zero Suicide Initiative.

Save to Library

Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.

Patient suicide attempts are considered never events. This funding announcement calls for program applications to motivate suicide prevention strategy implementation in the indigenous peoples’ community. The effort anchors on the Zero Suicide initiative to address unique challenges presented by the Indian health system.

AHRQ announces interest in research on digital healthcare safety.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.

Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication.

Save to Library

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.

National Prescription Drug Take Back Day.

Save to Library

Drug Enforcement Administration. October 23, 2021.

Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

Save to Library

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

Save to Library

US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request.

Save to Library

Agency for Healthcare Quality and Research. Fed Register. September 21, 2021;86:52471-52473.

This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Nursing Home Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Canadian Patient Safety Week.

Save to Library

Healthcare Excellence Canada

This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2021 observance, focusing on the importance of essential care partners, was held October 25th through 29th.

Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request.

Save to Library

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

Save to Library

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.

Use purple bracelets or wristbands only for do not resuscitate status - letter to industry.

Save to Library

Bethesda, MD: Food and Drug Administration; August 16, 2021.

Lack of standardization in processes, devices, and colors contributes to errors and patient harm. This letter to industry calls for medical device manufactures to use standard colors for patient identification wristbands to minimize confusion regarding do-not-resuscitate status.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

Save to Library

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Medical malpractice claims by members of the uniformed services.

Save to Library

Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17, 2021:32194-32215.

Organizations with safety cultures facilitate the ability for an injured patient to seek an effective response to untoward incidents. This United States rule outlines the standards that enable members of the armed forces to file claims should they be harmed while in the military health care system.

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

Save to Library

Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

2020 Eisenberg Award recipients announced by The Joint Commission, National Quality Forum.

Save to Library

Oakbrook Terrace, IL: Joint Commission: June 8, 2021.

The Eisenberg Award honors individuals and organizations who have made critical achievements toward patient safety and quality improvement. The 2020 honorees are Dr. David Gaba, Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL. The awards will be presented virtually during the National Quality Forum's annual meeting in July.

Common Formats for Patient Safety Data Collection: Diagnostic Safety 0.1.

Save to Library

The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.

Measurement of diagnostic errors is an important challenge in health care. This announcement calls for the review of Common Formats for Event Reporting--Diagnostic Safety or CFER-DS, and supplies links to the draft formats for public comment. The development of a standard system for voluntary reporting of diagnostic errors to patient safety organizations will support effective data collection and measurement. The process for submitting comments is now closed.

Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling.

Save to Library

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 4. 2021.

Anesthesia medications can be high risk should dosing errors occur. This company announcement reports a recall of two lots of anesthetics that have been mislabeled to mitigate the potential for patient harm due to misinformation.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users