The PSNet Collection

Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication.

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Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

Curated Libraries

Medication/Drug Errors

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

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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.

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

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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.

The Safety Competencies Framework.

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Ottawa, ON: Canadian Patient Safety Institute; 2008.

This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020.

A Thematic Analysis of HSIB's First 22 Investigations.

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Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.

Curated Libraries

Maternal Safety

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

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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.

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

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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.

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Never Events Analysis of HSIB's National Investigations Report.

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Farnborough, UK: Healthcare Safety Investigation Branch; January 2021.

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.

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021.

Vinca alkaloid misadministration is a persistent problem that results in patient harm and death. This alert raises awareness of label changes that aim to mitigate accidental spinal administration of the high-alert chemotherapy agent by supporting infusion bag administration only.

Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction.

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Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020. AHRQ Publication No. 20-0040-3-EF.

Checklists are considered a promising intervention to improve diagnosis because they can support clinical decision-making by ensuring that correct diagnostic steps are taken and that all possible diagnoses are not overlooked. This issue brief outlines how checklists have unachieved potential in clinical practice and their use can further guide decision-making and assure completeness of the diagnostic process.

Ensuring Healthcare Safety Throughout the COVID-19 Pandemic.

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US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.

The NHS Patient Safety Strategy.

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NHS Improvement.

The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.

Patient Safety Learning.

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Patient Safety Learning.

This website shares system-focused approaches to enhance patient safety. The organization offers white papers, an annual conference, and a social media portal to enable knowledge and evidence sharing among a wide range of health care stakeholders.

Addressing Problematic Opioid Use in OECD Countries.

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Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.

The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.

Healthcare Safety Investigation Branch.

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A1, Cody Technology Park, Farnborough, GU14 0LX.

Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

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Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role.

Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.

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US Food and Drug Administration; FDA.

Confusing labeling can affect safe medication preparation and administration. This safety announcement reviews case reports associated with inconsistent drug strength information that contributed to dosing errors of compounded injectable products.

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