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- Communication Improvement 1
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- Legal and Policy Approaches 2
- Logistical Approaches 1
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- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety
- Surgical Complications
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- Health Care Providers
- Latent Errors
- Medication Errors/Preventable Adverse Drug Events
- Postoperative Surgical Complications
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Study
Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.
Journal Article > Review
Neuman MD, Bateman BT, Wunsch H. Lancet. 2019;393:1547-1557.
The overprescribing of opioids for postsurgery pain can increase the potential for opioid dependence, misuse, and harm. Discussing this worldwide patient safety concern, this commentary summarizes clinician, patient, and systemic factors that contribute to the problem and outlines efforts to address the issue while enabling clinicians to provide safe pain therapy to patients.
Cases & Commentaries
- Web M&M
B. Joseph Guglielmo, PharmD; March 2007
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.