Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 2
- Education and Training
- Error Reporting and Analysis 6
- Human Factors Engineering 5
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 7
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 9
- MRI safety 1
- Nonsurgical Procedural Complications 2
- Surgical Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 15
- Health Care Providers 30
- Non-Health Care Professionals 8
- Patients 12
- Europe 2
- Canada 1
Search results for "Press Release/Announcement"
- Press Release/Announcement
- Education and Training
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
International Society for Quality in Health Care.
Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop physicians and leaders seeking to translate patient safety theory, clinical practice improvements, and implementation science to health care environments in developing countries. The current application process is now closed.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
Canadian Patient Safety Institute.
Washington DC: National Academy of Medicine and the Aspen Institute.
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the United States, the complexity of the problem has hindered the effectiveness of improvement efforts. This website highlights the work of a multiorganizational collaborative to explore systemic solutions to address the opioid crisis. An Annual Perspective discussed the impact of the opioid epidemic on patient safety.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
Surgical fires can result in patient harm. This announcement provides information about causes of surgical fires and reviews FDA recommendations to prevent them, such as presurgery fire risk assessment, promoting team communication, and fire management planning. A WebM&M commentary discussed common sources of operating room fires and how to reduce risks.
Drug Enforcement Administration. April 28, 2018.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.
The Institute for Safe Medication Practices.
Structured interaction with a wide variety of experts and environments enables medication safety improvement. This 2-week educational program provides international clinicians with the opportunity to work with leaders based in the United States to engage in incident analysis, project design, and strategic planning to enhance medication safety efforts in their home countries.
Food and Drug Administration, Institute for Safe Medication Practices.
This fellowship program provides clinicians with learning opportunities at the Institute for Safe Medication Practices and the US Food and Drug Administration. The appointment consists of a pair of successive 6-month positions designed to provide experience in both system improvement and regulatory approaches to enhance medication safety. The process for submitting applications is now closed.
Institute for Safe Medication Practices.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.
Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.
Accreditation Council for Graduate Medical Education.
Implementation of resident duty hours, meant to address fatigue in health care, has long been a subject of patient safety discussions. This website provides a summary of proposed changes to the current ACGME residency Common Program Requirements that shape working hours, offers rationale for the revisions.
Society to Improve Diagnosis in Medicine.
Diagnostic error is garnering increased attention as a key area of focus in patient safety improvement. This fellowship program for physicians who have completed their residency will provide the opportunity to build expertise in enhancing diagnostic safety. The application for the 2019–2020 program is closed.
Horsham, PA: Institute for Safe Medication Practices.
There is a noted lack of agreement on measures to study and track safety hazards and the effectiveness of improvement strategies. This survey seeks input from the field to inform the development of a list of medication-related measures to communicate concerns related to drug class, technology use, and medication administration practices as a way to provide data to senior management in an easily accessible format.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.
International Society for Quality in Health Care.
This announcement highlights a peer learning initiative that builds on existing programs and interdisciplinary networks to develop participants' understanding about and skills for improving health care internationally.
Rockville, MD: US Food and Drug Administration; 2013.
To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.
FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013.
This announcement explains a label change to a medication patch intended to reduce risk of accidental exposure.