The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety. The 2023 awards recognized Susan Donnell Scott PhD for her work focusing on support mechanisms for clinicians involved in medical error.

The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.

This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, six sigma, and high reliability organizations.

Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2022-2023 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission closes June 30, 2023.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.