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Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
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.
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. A March 18, 2022 webinar will highlight factors contributing to medication errors in the home and outline strategies to reduce their impact.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.
The Joint Commission.
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 and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. 

116th Congress 2d session. December 10, 2020.

The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic improvement. The ‘‘Improving Diagnosis in Medicine Act of 2020’’ outlines characteristics of a proposed Federal program to enhance agency cooperation and coordination to improve diagnosis in health care by addressing systemic weaknesses, knowledge gaps, and training issues in the workforce.
Farooqi OA, Bruhn WE, Lecholop MK, et al. Int J Oral Maxillofac Surg. 2020;49:397-402.
The over-prescribing of opioids is a recognized contributor to patient harm. This multidisciplinary panel developed six recommendations to manage pain after dental procedures while reducing harm to patients: (1) Offer alternatives to opioids after dental surgery to interested patients when clinically appropriate. (2) Avoid prescribing opioids after dental surgery if pain is comfortably management with over-the-counter medication. (3) Advise patients about non-pharmacological therapies (e.g., cold, heat, distraction). (4) Teach patients to maximize non-narcotic (over the counter) pain medication with scheduled dosing unless contraindicated. (5) Engage in shared decision-making with patients. (6) Consider factors such as medical contraindications, risk for addiction, and risk aversion when prescribing opioids.

Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.

Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations  to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.
Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.
Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.
Academy of Medical Royal Colleges; AMRC.
Miscommunication due to clinician use of medical jargon and limited patient health literacy is a persistent problem. This guidance suggests that physicians in the United Kingdom adopt a more direct approach to communication with their patients, such as encouraging physicians to write care letters and visit summaries directed to their patients.
American College of Physicians; ACP.
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. This position paper highlights seven recommendations to address patient safety challenges in the ambulatory environment, including enhancing patient health literacy, utilizing team-based care models, and establishing a national effort to reduce patient harm across all settings of health care.

Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.

Patient safety in the ambulatory environment has received less attention than hospital settings. This guideline provides recommendations to reduce transmission of infectious agents in pediatric ambulatory care, such as policy review and development, education for personnel, and hand hygiene precautions.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65:1-49.
Opioid pain medications carry high risk for adverse drug events and misuse. Due to climbing rates of opioid use and associated adverse events, the Centers for Disease Control and Prevention released new guidelines for prescribing opioid medications for chronic pain. These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life care. The authors recommend using opioids for chronic pain only if nonopioid medications and nonpharmacologic approaches to chronic pain are not effective and prescribing immediate-release instead of long-acting medications. For acute pain, they recommend limiting duration of therapy, stating that more than 1 week of medications should rarely be needed. The guidelines also suggest minimizing concurrent use of opioids and other sedating medications and dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids.
Full Committee Hearing. US Senate Committee on Health, Education, Labor and Pensions (September 16, 2015)
Enabling patients to access their medical records has been found to enhance patient–clinician communication and uncover errors. This hearing explored the importance of providing patient access to personal health information to improve care. Testimonies discussed the need to have one integrated patient record and to design patient portals around human factors approaches to augment usability.