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.

This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

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. 

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 fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.