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Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.
This annual report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.

Rockville, MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Pub. No. 20-0048.

AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2020, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between July 2012 and December 2019. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. This iteration of the chartbook contains an additional 619,111 reports not included in the prior NSPD chartbook.  

London, UK: General Medical Council; September 14, 2020.

Physician caregiving effectiveness can be tested during crisis situations. This guidance shares recommendations for leaders assessing complaints against physicians during the COVID-19 pandemic to consider extenuating circumstances when determining next steps in managing the response to poor care delivery. 

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the year 2030. The Foundation supports several awareness initiatives to drive improvements associated with its strategic aims that include promoting transparency, realigning safer care incentives, and informing patients and families about patient safety.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.
Health Quality & Safety Commission New Zealand.
This Web site hosts tools and resources associated with a national campaign to augment patient care. The initiative aims to build collaborative programs across New Zealand to reduce falls, health care–associated infections, medication errors, and harm related to surgery.
Fridkin S, Baggs J, Fagan R, et al. MMWR Morb Mortal Wkly Rep. 2014;63:194-200.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Minnesota Hospital Association; MHA.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; October 2011. Report No. OEI-01-08-00590.
The Office of the Inspector General (OIG) has conducted a series of analyses of adverse event incidence among Medicare beneficiaries. This report evaluates how hospitals, the Centers for Medicare and Medicaid Services (CMS), and state agencies have responded to particularly serious adverse events. The OIG found that investigations into errors were generally timely and resulted in changes with the potential to improve patient safety. However, the OIG faults state agencies for failing to communicate findings to The Joint Commission and for failing to monitor long-term safety performance at hospitals where errors occurred. The report outlines specific recommendations for CMS and state agencies to ensure that lasting safety improvement comes about after serious errors occur.
Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH.
This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.

NHS Wales; National Health Service.

This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.
Washington State Department of Health.
This Web site provides never event data to promote transparency and informed consumer decision making.