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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.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225: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.
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;47:394-397.
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.

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.
NHS Improvement.
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.

American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2016;128:e237-e240.

Checklists are a common strategy to improve safety in health care settings, but they may not be successfully implemented. This review discusses the use of checklists as a cognitive aid to improve communication and reduce variation. The authors outline how to choose processes that would benefit from a checklist and suggest that providers using the checklist be actively involved in their development, implementation, and evaluation.
Putnam K. AORN J. 2015;102:P11-P13.
Retained surgical items are considered a sentinel event in perioperative care. This guideline suggests strategies such as improving team communication, standardizing protocols for surgical counts, and limiting distractions to address this persisting problem.
US Department of Health and Human Services; HHS; Food and Drug Administration; FDA.
Heparin is a high-alert anticoagulant that has been associated with patient harm due to issues with administration and contamination. This draft guidance seeks to engage insights from the field to help improve labeling practices. The deadline for officially submitting comments was October 7, 2015.
Heinemann L, Fleming A, Petrie JR, et al. Diabetes Care. 2015;38:716-22.
Insulin is a high-alert medication that can lead to harm if incorrectly administered. Insulin pump problems can be caused by human, mechanical, or drug stability failures. This policy statement describes ways to use adverse event data, manufacturer information, and technical specifications to enhance the safety of insulin therapy.

Neville K, Galinkin JL, Green TP, et al; Committee on Drugs of the American Academy of Pediatrics. Pediatrics. 2015;135(4):784-787.

Accidental overdoses can occur when oral medications are given to children using teaspoons as measurement devices. This policy statement recommends use of milliliter-based dosing devices to enable metric-based administration of liquid medications to pediatric patients.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February 11, 2015.
Mistakes due to small-bore Luer connector similarities can contribute to patient harm. This guidance provides ways for manufacturers, policy makers, and product designers to prevent misconnections, including recommendations regarding improvements for labeling, user testing, and risk assessment.
Bearman G, Bryant K, Leekha S, et al. Infect Control Hosp Epidemiol. 2014;35:107-21.
This guidance examined literature and hospital policies around how health care staff clothing can contribute to health care–associated infections (HAIs). The investigators reveal patients' and health care workers' perceptions regarding clinician attire and recommend research to improve understanding about its potential to spread pathogens.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.