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The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;Epub Nov 19.
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.

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

American College of Emergency Physicians, National Association of Emergency Medical ServicesAnn Emerg Med. 2021;78(3):e37-e57. 

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.
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. 
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225(5):b43-b49.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Sentinel Event Alert. 2018;(59):1-9 (revised June 18, 2021).
The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units. Other factors associated with violence in health care settings include stressful conditions, understaffing, and lack of organizational policies for recognizing and deescalating hostile behaviors. The alert suggests numerous strategies health care organizations can take to mitigate workplace violence, such as establishing systems across the organization that enable reporting of workplace violence and developing quality improvement initiatives to reduce such incidents. A past PSNet perspective explored how a team at Beth Israel Deaconess Medical Center developed a process to improve workplace safety.
Sentinel event alert. 2010:1-3.
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
Jt Comm J Qual Patient Saf. 2021;47(6):394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.

Sentinel Event Alert. Feb 2, 2021;(62):1-7. 

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic. 

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.
Morton CH, Hall MF, Shaefer SJM, et al. J Obstet Gynecol Neonatal Nurs. 2021;50(1):88-101.
Individuals involved in adverse maternal events require support both physically and emotionally. This guidance combines readiness, recognition, response, and reporting and systems-learning steps to aid birthing facility nurses and management in providing standardized help for mothers, families, and care team members that experience care-related harm.  

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.
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156(1):76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
Cicero MX, Adelgais K, Hoyle JD, et al. Prehosp Emerg Care. 2020;25(2):294-306.
This position statement shares 11 recommendations drawn from a review of the evidence to improve the safety of pediatric dosing in pre-hospital emergent situations. Suggestions for improvement include use of kilograms as the standard unit of weight, pre-calculated weight-based dosing, and dose-derivation strategies to minimize use of calculations in real time.   
Am Geriatr Soc. 2020;68(5):908-911.
This policy brief presents the American Geriatric Society’s recommendations for caring for patients with COVID-19 in nursing homes and long-term care facilities. Recommendations focus on the production and distribution of personal protective equipment (PPE), patient transfer between hospitals and nursing homes, public health planning, workforce issues, and payment and tax relief for nursing homes. The brief reflects federal guidance as of April 4, 2020.