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.

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.

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.

This resource collection highlights news items that examine the potential for patients to be put at risk for emotional, financial, or physical harm.

Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news segment highlights one family's experience with poor care stemming from disrespect and premature closure that resulted in missed diagnosis, unnecessary care, and patient death. The story is coupled with a broader discussion on the extent of diagnostic errors and reasons they occur.

To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.

The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.

A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.

This new organization fosters collaboration between governments and stakeholders in developing patient safety initiatives. This Web site provides tools for health care professionals and patients. It was formed in March 2021 through the merging of the Canadian Foundation for Healthcare Improvement and the Canadian Patient Safety Institute.

Never events provide organizations with motivation to analyze and learn from errors due to their catastrophic nature. This National Learning Report provides a thematic examination of never events in the National Health Service (NHS). The report found misattribution of incidents as never events in the NHS due to lack of systemic factors as contributors to those events. A revision of the NHS never events list is recommended. 

Misdiagnosis can endure 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. 

Patients and families experiencing medical error may not always have access to the support needed to navigate the system to inform improvements and receive appropriate restitution. This hotline will provide general information to individuals that contact the organization for help when they feel an error may have occurred in their care or the care of a family member. 

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. 

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic. 

This reoccurring 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. Older reports are also available.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.    

Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.