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Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; May 18, 2022.
This guidance outlines design elements that reduce errors associated with medication labels. Improvements suggested include tall-man lettering use, look-alike / sound alike avoidance and abbreviation minimization.
Jang S, Jeong S, Kang E, et al. Pharmacoepidemiol Drug Saf. 2020;30:17-27.
Older patients are at greater risk of experiencing adverse drug events and recent efforts have focused on avoiding prescribing high-risk medications to these patients. This study found that while implementation of a nationwide prospective drug utilization review lowered some potentially inappropriate medication prescribing among older adults in South Korea, there were no statistically significant changes in prescribing trends.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.

Zajicek J. Belmont Health Law J. 2020;4:79-135.

Intent to harm is a primary factor in the criminalization of patient injury. This article discusses the increase of criminal legal action to medical error and its negative affect. The author summarizes alternative strategies for addressing clinician responsibility for harmful errors and suggests improvements in current approaches to avoid the use of prosecutorial methods to hold those involved accountable for harm.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Morgan L, Benson D, McCulloch P. BMJ. 2019;364:l1037.
Investigations into medical mistakes that result in patient harm should be fair, complete, and consider the context of the event. This commentary examines investigation processes in the United Kingdom and highlights the importance of understanding how human factors contribute to error to help effectively assess each incident and support transparency and improvement.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.
Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37:1862-1869.
System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment. This news article reports on problems associated with ambulatory use of insulin pumps submitted to a Food and Drug Administration database.
Joseph A, Henriksen K, Malone E. Health Aff (Millwood). 2018;37:1884-1891.
The built environment influences the safety and effectiveness of care delivery. This narrative review examines how care facility design can reduce health care–associated infections, falls, and medication errors. The authors provide suggestions regarding a range of facility design strategies and discuss how accreditation, funding, and policy organizations can support design projects as improvement efforts.
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. N Engl J Med. 2017;377:1551-1558.
Under the Centers for Medicare and Medicaid Service Hospital Readmissions Reduction Program, hospitals are subject to nonpayment if patients with certain medical conditions are readmitted. Research supports the effectiveness of this program in decreasing readmissions and some have argued for expansion to a hospital-wide readmission measure. Using Medicare claims data, investigators concluded that transitioning to a hospital-wide readmission measure would lead to greater penalties for safety-net hospitals compared to other hospitals, a concern that has been raised with regard to Medicare's Hospital-Acquired Condition Program.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
Murray P. Washington, DC; Senate Health, Education, Labor, and Pensions Committee; 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. June 30, 2015.
Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.