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Iredell B, Mourad H, Nickman NA, et al. Am J Health Syst Pharm. 2022;79:730-735.
The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.
Horsham, PA: Institute for Safe Medication Practices; 2022.
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. 

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. 2018:1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.

Sentinel Event Alert. March 31, 2015;(54):1-6.

The introduction of information technology (IT) has transformed health care, but it is clear that the rapid uptake of IT has profoundly changed clinician workflow, resulting in unintended consequences that in some cases have harmed rather than helped patients. These unintended consequences include new types of errors resulting from computerized provider order entry, alarm fatigue arising from the proliferation of well-intended safety alerts, and problems with poor interoperability of different electronic medical record systems. The Joint Commission issues sentinel event alerts periodically to highlight emergent safety issues, and this alert describes some of the 120 sentinel events reported to The Joint Commission since 2003 that were determined to be related to IT. Several recommendations to prevent IT–related safety threats are discussed, including improving safety culture by creating a shared sense of responsibility between users and developers, paying careful attention to safe IT implementation, and engaging leadership to provide oversight in health IT planning, implementation, and evaluation. The hazards and benefits of health IT are the subject of a recent book by a prominent patient safety expert.
Improvement C on PS and Q, Management C on P. Obstet Gynecol. 2015;125:282-3.
Despite improvements associated with health information technology (IT), consistently safe use has been difficult to achieve. This guideline describes the benefits and challenges associated with various components of health IT and suggests that enhanced interoperability and mandatory reporting for health IT errors are needed to improve safety.
Sentinel Event Alert. 2010;44:1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.
Sentinel event alert. 2008:1-4.
As health information technologies such as computerized provider order entry are implemented more widely, awareness of the unintended consequences of these technologies has increased. Both electronic medical records and computerized order entry have been associated with significant problems relating to altered workflow and communication patterns. This sentinel event alert from the Joint Commission reviews the types of adverse events associated with information technology and gives detailed recommendations for how institutions should integrate new technologies. The alert stresses the importance of involving frontline staff in the development and implementation process and also recommends careful postimplementation monitoring for errors and near misses associated with new technology.
Sentinel Event Alert. 2008;41:1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.