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The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.
AHA Training. March 6-7, 2021. Hyatt Regency Chicago, Chicago, IL.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005.

This analysis of reports submitted by Patient Safety Organizations during the early months of the COVID pandemic found that patients testing positive for COVID-19 or being investigated for carrying the virus was the most frequently reported patient safety concern (26.6%). In addition, patients and staff being exposed to individuals who had tested positive for COVID-19 was identified as a patient safety issue in 18.2% of the records analyzed.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.

Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum. The deadline for submitting comments is January 10, 2022.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2:00-3:00 PM (eastern).

An organization’s understanding of its culture is foundational to patient safety. This webinar will introduce the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session will cover the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 

December 16, 2021. 

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.

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

AHRQ’s Hospital Survey on Patient Safety Culture™ (SOPS®) ask health care providers and staff about the extent to which their organizational culture supports patient safety. The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding. You can learn more about the supplemental items and can register for a webcast introducing the Workplace Safety items here: Surveys on Patient Safety Culture™ (SOPS®) | Agency for Healthcare Research and Quality (ahrq.gov)  

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.

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.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.
NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
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.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.