Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.

This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.

Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.

Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.

The perioperative environment is vulnerable to medication error. This newsletter article highlights how container confusion and syringe swaps are particularly susceptible to failures and offers recommendations to address risks.

This newsletter article discusses an adverse drug event involving a patient who died after receiving a neuromuscular blocker instead of a seizure control agent. The preparation error was associated with incorrect labeling. Because neuromuscular blocking agents are considered high-alert medications, more robust administration processes should be employed to reduce the potential for mix-ups.

This piece discusses second victims and describes how five factors can help clinicians involved in adverse events.

This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.

This newspaper article reports on a fatal medication error involving an anticoagulant overdose.

This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.

This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.

This news story discusses Utah sentinel event statistics and compares them with 2007 data.

This article reports on the mistaken administration of a high-alert medication, similar to a prior sentinel event, and describes strategies for preventing such errors.

This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.

This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.