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Journal Article > Commentary
Mueller BU, Neuspiel DR, Fisher ERS; Council on Quality Improvement and Patient Safety. Pediatrics. 2019;143:e20183649.
This updated policy statement from the American Academy of Pediatrics reviews the epidemiology of medical errors in children, examines unique issues in safety for pediatric patients, and discusses specific approaches to improving safety in pediatrics. The article emphasizes the responsibility of pediatricians to be familiar with patient safety concepts and techniques, and the importance of establishing a culture of safety in both inpatient and outpatient settings. The article concludes with a series of specific recommendations for advancing the science of patient safety within the field of pediatrics.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. April 8, 2013;(50):1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Journal Article > Commentary
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.
Legislation/Regulation > Multi-use Website
Oakbrook Terrace, IL: The Joint Commission; 2018.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, and specific clinical harms such as falls and pressure ulcers. The 2019 NPSGs include two significant revisions. Hospitals and behavioral health facilities now must maintain specific protocols to prevent inpatient suicide, including conducting environmental risk assessments, screening patients admitted for behavioral health reasons for suicide risk, and implementing tailored suicide prevention plans for high-risk patients. The NPSG on ensuring the safety of anticoagulant medications has also been updated to incorporate new evidence in this area.