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Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.

This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.

This guide offers tools and strategies to ensure that care in the ambulatory setting is safely provided, evidence-based, and aligned with Joint Commission requirements.

This article describes how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.

This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.