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ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is November 19, 2021.
Fauer AJ. Herd. 2021;Epub Jun 26.
The physical design or layout of a clinical space can affect patient safety.  This mixed-methods study of 8 ambulatory oncology offices found that the physical layout (e.g., visibility of patients during infusion) and location (i.e., proximity of infusion center to prescribers) impacted communication and patient safety. Consultation with clinicians regarding the physical environment prior to design of ambulatory oncology clinics could improve communication and therefore patient safety.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17(4):273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  

ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.

Look-alike labeling is a known contributor to medication errors. This article summarizes common factors resulting in packaging and labeling concerns. Recommendations for improvement include partnerships with industry regarding the use of risk management practices to improve the accuracy of labeling prior to product launch.
Biquet J-M, Schopper D, Sprumont D, et al. J Patient Saf. 2020;Epub Nov 20.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.  

Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 7, 2020. 

Nonprescription drugs are commonly associated with medication errors. This draft guidance seeks to provide a structure for industry to reduce instances of drug name confusion in nonprescription formulas of prescription medications. It describes the US Food and Drug Administration (FDA) vetting process for drug names to improve naming actions prior to submission to the agency. The timeline for submitting comments is early February 2021. 

Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 2020.

Look-alike and sound-alike names weaken the safety of medication use. This guidance provides a structure for industry to reduce instances of drug name similarities and describes the US Food and Drug Administration (FDA) vetting process for drug names to improve naming actions prior to submission to the agency.
Samad F, Burton SJ, Kwan D, et al. Pharmaceut Med. 2021;35(1):1-9.
Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.
Ferdinand KC, Nasser SA. J Am Coll Cardiol. 2020;75(21):2746-2748.
The authors of this editorial discuss the disproportionate burden of COVID-19 on African Americans and highlight ways in which the pandemic has exacerbated existing disparities in cardiovascular disease and systematic failures in the health care system. The authors propose several actions to mitigate the effects of the pandemic and work towards addressing existing disparities and underlying structural factors, including targeted testing in housing environments with limited ability to socially isolate, encouraging team-approach telemedicine, and supporting low-cost or free online physical activities.
Quick Safety. 2020;54:1-4.
Effective practice in times of crisis is reliant on a workforce that feels safe and supported by their organization. This alert highlights distinct stressors to clinical psychological health during the COVID-19 pandemic and lists actions organizations can take to remove barriers that may hinder clinicians seeking the help they need in times of high stress.
Dietz L, Horve PF, Coil DA, et al. mSystems. 2020;5.
This article discusses the potential for COVID-19 transmission via the built environment (e.g., computers, counters, door knobs, faucets); the authors suggest mitigation strategies that can potentially prevent or reduce virus transmission that may be implemented in the community at large (government buildings, school districts, churches, assisted living, daycares) such as sanitizing surfaces, reconfiguring HVAC operational practices, spatial configuration, etc. The authors also discuss special considerations for healthcare settings, such as room pressurization and ventilation.
Wang GS, Reynolds KM, Banner W, et al. Acad Ped. 2020;20(3):327-332.
Using a national surveillance system to identify adverse events A(Es) involving common oral over-the-counter (OTC) cough and cold medications, an expert panel evaluated and assigned causal relationships between AEs and active ingredients in the medications. Of the 4,756 adverse events identified, 10.8% were due to a medication error; nearly all of these errors (93.2%) were attributed to the wrong dose of medication. The most common medication errors involved diphenhydramine and dextromethorphan. Almost half of medication errors (45.8%) involved children between the ages of 2 and 5 years old and involved administration by either a parent (45%) or alternative caregiver (28.8%).  Continued standardization of medication measuring devices, concentrations and units, as well as consumer education, is needed to further decrease medication errors from these common OTC medications.

Wilson T. How Collective Design Triumphed Over Competition in the Fight Against HAIs. St Louis, MO; Facilities Guidelines Institute; 2020.

Health care environment design can affect safety. This report shares the results of a patient room design competition seeking solutions to minimize conditions contributing to health care- associated infections (HAI). The designs considered elements such as location of hand-washing sinks and building material selection as HAI reduction strategies.
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
Health systems are encouraged to strive for zero preventable harm, but achieving this goal requires a comprehensive, systems-focused effort. This paper discusses the rationale for using ‘zero harm’ as a patient safety goal, and the importance of broadening the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring beyond the hospital and across the care continuum. Four key elements required for successful systems change resulting in safety improvements are discussed: (1) change management, (2) culture of safety, (3) a learning system, and (4) patient engagement and codesign of healthcare.
Colleges A of MR. London, UK: Academy of Medical Royal Colleges; 2020.
A foundational understanding of safety is core to building reliable care processes and teams. This report outlines a curriculum that was developed in response to a national improvement strategy for National Health Service staff. The training program highlights the themes of the systems approach, risk competencies, human factors and safety culture as linking content domains together to develop safe practitioners.
Emani S, Sequist TD, Lacson R, et al. Joint Commission journal on quality and patient safety. 2019;45:552-557.
Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.
Center for Health Design. Concord, CA: Center for Health Design; 2018.
Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and research to address vulnerabilities to this patient population. Design interventions to improve the service environment are also available.