Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Assessment can identify the current state of a process or program to reveal areas of weakness and inform improvement implementation efforts. This scenario-based tool focuses on 10 areas of an organization’s journey to support diagnostic safety.

This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 

Human factors engineering approaches improve safety, efficiency, and effectiveness in both normal and challenging times. This tool shares a human-factors structured approach to improving technology integration and adaptation into work processes to reduce burnout and its negative effects on worker and clinician wellbeing. 

Medication management has been affected in a variety of settings due to the COVID-19 pandemic. This guide highlights strategies to ensure safe medication delivery in long term care. Tactics highlighted include medication discontinuation and alignment of medication administration times.

Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.

Texting as a communication method in the clinical environment is convenient, but it introduces distraction that can result in error. This survey sought to track the prevalence of medical order texting to better understand its impact on care processes. 

The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.

Electronic health records have potential to improve health care, but they may also introduce unanticipated risks. This report describes the results of a group convened to explore strategies to enhance health IT safety. Focusing on copying and pasting health data from one record to another as the first area of concern, the report recommends enabling systems to identify what data has been copied in the electronic health record and where it came from, providing training to ensure the safe use of copy and paste, and regularly track and assess copying and pasting practices. The report includes tools to related to the recommendations. A WebM&M commentary explores the hazards associated with the use of copy and paste.

This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.

This column offers advice for consumers on what personal health and medical information to prepare before going to the emergency department.

This document summarizes the experience of numerous AHRQ-funded programs in implementing bar-coded medication administration.

This FAQ answers questions related to the FDA machine-readable bar-coding requirement for blood components.