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Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.

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 to summarize preemptive actions and implementation strategies for prevention of HAIs.

A clinician's knowledge of an existing condition can implicitly affect treatment recommendations and decisions. This alert highlights the presence of diagnostic overshadowing as a type of bias that is prone to affect disadvantaged or stigmatized patient populations. Listening training programs, improved use of patient data review, and assessment techniques are recommended to trigger diagnostic curiosity to encourage complete decision-making methods when serving patients.

This guidance outlines design elements that reduce errors associated with medication labels. Improvements suggested include tall-man lettering use, look-alike / sound alike avoidance and abbreviation minimization.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce 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. 

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.