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Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;Epub Jul 30.
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.

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.
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. The 2021 NPSGs reflect no changes from the 2020 goal set. 
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.

The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, American Association of Critical‐Care Nurses, AACN, and American College of Chest Physicians. March 26, 2020.

Innovations must be incorporated into care processes with safety in mind. This announcement shares insights to mitigate strategies that may cause patient harm through alternative use of ventilators to support multiple patients with compromised respiratory function.

American College of Radiology. March 11, 2020.

As COVID-19 spreads globally, there is growing interest in methods for rapid diagnosis and the risk of diagnostic error. Delayed diagnosis of COVID-19 may lead to worse patient outcomes and increased exposure of healthy individuals to the novel coronavirus. Two early studies suggested that chest CT may have a sensitivity as high as 97%. However, higher quality studies have shown that the sensitivity of chest CT is only 67-93% among patients with viral pneumonia and imaging features must be interpreted with caution when the prevalence of SARS-CoV-2 infection is low. Based on the risks of misdiagnosis and viral transmission, the American College of Radiology recommends that CT should not be used to screen for or as a first-line test to diagnose COVID-19. CT should be reserved for hospitalized, symptomatic patients with specific clinical indications.  
Farooqi OA, Bruhn WE, Lecholop MK, et al. Int J Oral Maxillofac Surg. 2020;49(3):397-402.
The over-prescribing of opioids is a recognized contributor to patient harm. This multidisciplinary panel developed six recommendations to manage pain after dental procedures while reducing harm to patients: (1) Offer alternatives to opioids after dental surgery to interested patients when clinically appropriate. (2) Avoid prescribing opioids after dental surgery if pain is comfortably management with over-the-counter medication. (3) Advise patients about non-pharmacological therapies (e.g., cold, heat, distraction). (4) Teach patients to maximize non-narcotic (over the counter) pain medication with scheduled dosing unless contraindicated. (5) Engage in shared decision-making with patients. (6) Consider factors such as medical contraindications, risk for addiction, and risk aversion when prescribing opioids.

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.
Bickham P, Golembiewski J, Meyer T, et al. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.