Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares  errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.

Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.

Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.

Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.

Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.

The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article reports on ways physicians can help proactively recognize and address the potential for patient opioid misuse, such as adherence to guidelines and monitoring patient opioid use. An Annual Perspective discussed the opioid crisis as a patient safety problem.

Strategies to manage pain safely have been reexamined in light of the opioid epidemic. This report highlights Joint Commission guidelines for pain assessment and management and outlines accreditation expectations for leadership, medical staff, medical services, and performance improvement.

Reporting on the importance of a supportive workplace environment that engages employees in tasks to help ensure safety, this news article discusses root causes for low staff morale in the laboratory environment and suggests tactics to build healthy staff relationships.

This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.

This article presents three principles that physicians can leverage to support highly reliable, safe care: do no harm, evidence-based practice, and patient-centered teamwork.