Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.

Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk. 

This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.

The Joint Commission requires time outs prior to surgical incision. This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.

This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.

This report discusses the impact that automated technologies, such as radio frequency identification (RFID) and barcoding, could have on health care in the United Kingdom and provides a plan to support their adoption in the National Health Service.

According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.

This supplemental advisory recommends that a limited, standard set of colors and corresponding terms accompany wristband use.

This Web site provide resources for improving patient safety in the National Health Service, including a place for practitioners to ask questions and share experiences with one another.