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When we're all responsible for a patient's death, no one is.

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Prasad V, Medpage Today. November 16, 2021.

The issue of system versus individual accountability can challenge the orientation of safety improvement efforts. This opinion piece discusses the importance of physician recognition of decision making mistakes and the downside of the evolution of morbidity and mortality conferences away from that approach.

Disrespectful behavior in healthcare: has it improved? Please take our survey!

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ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

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

Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?

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Clark C. MedPage Today. September 14, 2021.

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.

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Maternal Safety

Geriatric medication reconciliation in the home setting.

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Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

Drug shortages amid the COVID-19 pandemic.

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Bookwalter CM. US Pharmacist. 2021;46(2):25-28.

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

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ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing.

Not ‘just depression.’ She seemed trapped in a downward mental health spiral. The real cause was a profound shock.

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Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.

Learning from errors with the new COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education.

A night in the hospital, from both ends of the stethoscope.

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Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

COVID-19 Content. ISMP Medication Safety Alert!

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March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.

Doctors' unconscious bias affects quality of health care services, research shows.

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Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

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ISMP Medication Safety Alert! Acute care edition. July 30, 2020;25(15).

This article reports on the results of a survey on the use of practices to improve the safety of prescribing and dispensing of long-acting opioids and use of the override feature in automated dispensing cabinets. The approximately 250 hospitals responding shared experience indicating weakness in implementing improvement efforts on the two practices studied. The results found that hospitals employing a medication safety officer had stronger uptake of the best practices.

Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color.

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Mcfarling UL. Stat. 2020;July 21.

Dermatologists rely on visualization techniques to enhance diagnosis in their practice. This article highlights the unavailability of appropriate tools for assessment of disease on black and brown skin as a problem that reduces the safety and effectiveness of care for this patient population.

Missed and delayed diagnoses of non-COVID conditions--collateral harm from a pandemic.

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Carr S. ImproveDx. 2020;7:1-5.

The coronavirus pandemic has disrupted patient care seeking behaviors. This article discusses this phenomenon and its impact on the timing of diagnosis due to fear of contracting COVID-19 or threats resulting from the economic shutdown implemented to reduce spread of the virus.

Doctors and dentists still flooding U.S. with opioid prescriptions.

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Mann B. National Public Radio. 2020;July 17.

Despite efforts to reduce opioid prescribing for pain management, physicians and dentists still overprescribe these medications. This news story shares concerns regarding how engrained the reliance on medications for pain management is to the culture of care and its role in opiate dependence and abuse.

Promoting psychosocial well-being of health care staff during crisis.

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Quick Safety. June 3, 2020;(54):1-4.

Effective practice in times of crisis is reliant on a workforce that feels safe and supported by their organization. This alert highlights distinct stressors to clinical psychological health during the COVID-19 pandemic and lists actions organizations can take to remove barriers that may hinder clinicians seeking the help they need in times of high stress.

I can't turn my brain off.

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Hoffman J. New York Times. May 16, 2020.

Health care worker stress is a known contributor to disruptive behavior, error and clinician suicide. This story discusses the impact of the COVID-19 pandemic on psychological strain in clinicians and highlights peer support and other techniques to mitigate its negative effects.

There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on illicit drugs.

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Guirguis A. The Pharmaceutical Journal. 2020;304.

Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.

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