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This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

Drug diversion can result in patient harm due to reduced medication availability, impaired clinician performance, and loss of trust. This webinar discussed the impact of drug diversion at a system level and outlined steps an organization can take to minimize this risk through workplace health strategies and stewardship programs.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

This annual report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem. 

Medication error reporting is key to understanding failures, identifying risk and informing improvement. This webinar discussed approaches to internal reporting and challenges to reporting success.    

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.

Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.

Structured interaction with a wide variety of experts and environments enables medication safety improvement. This 2-week virtual educational program provides international clinicians with the opportunity to work with leaders based in the United States to engage in incident analysis, project design, and strategic planning to enhance medication safety efforts in their home countries.

Partnerships between physicians and patients can yield important outcomes that support safety improvements. This radio segment reports insights from both the patient and clinician involved in an adverse event and how this incident launched an organization that focuses on support for patients and clinicians that have been affected by medical errors.

Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.

Errors in the prescribing process can lead to adverse drug events. This slide set provides information about common problems in prescribing such as selecting the wrong drug in a drop-down menu, formulation mix-ups, alert fatigue, poor quality of data in health information systems, and use of ambiguous abbreviations.

Spotlighting how pharmacies have reported 194 serious medication errors to the Massachusetts State Department of Public Health since 2010, this news video raises concerns about production pressures and other process issues that may have contributed to the mistakes.

Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.

This video news segment highlights the persistent risks of adverse drug events in nursing homes, particularly overprescribing of antipsychotic drugs, and reveals how one state developed a program to reduce medication errors for older patients in residential facilities.

This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.