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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 6
- Error Reporting and Analysis
- Human Factors Engineering 5
- Legal and Policy Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 9
- Research Directions 1
- Technologic Approaches 2
- Device-related Complications 8
- Diagnostic Errors 1
- Identification Errors 1
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 11
- MRI safety 2
- Surgical Complications 4
- Transfusion Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 20
Health Care Providers
- Nurses 3
- Non-Health Care Professionals 8
- Patients 6
- United States of America 34
Search results for "Error Reporting and Analysis"
Federal Register. October 22, 2010;75:65359-65360.
This announcement discusses the Patient Safety Act, describes the role of Common Formats in collecting adverse event data through Patient Safety Organizations, and calls for feedback from the field to guide modifications.
National Quality Forum.
Patient safety organizations collect data across various systems and states. This announcement calls for review of the current beta version of the common formats developed to provide a standardized method to collect and report incident data to patient safety organizations. The current comment period is of open duration.
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.
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.
Palo Alto, CA: Gordon and Betty Moore Foundation; November 1, 2018.
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite an increasing focus on diagnostic error, accurate measurement and implementation of effective strategies for mitigating its adverse effects remain challenging. The Gordon and Betty Moore Foundation recently announced a new $85 million initiative focused on diagnostic excellence that takes into account health care costs, timeliness, and individual patient needs. This initiative will focus on three clinical areas including cancer, infections, and cardiovascular events. Through this funding, the foundation hopes to stimulate novel approaches to measuring diagnostic performance and plans to assess the effectiveness of new technologies in improving the diagnostic process. A PSNet perspective highlighted ongoing challenges related to diagnostic error.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
Preventable patient harm is a global public health concern. This announcement highlights a new partnership initiative co-led by the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement. The committee was formed in response to a call to coordinate a national plan and set of priorities for patient safety improvement efforts across public health and medical care communities.
Institute for Safe Medication Practices.
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.
National attention has focused on efforts to address adverse drug events. This call for comments seeks insights regarding revisions to a 2014 action plan that highlighted how to reduce adverse drug events associated with anticoagulants, diabetes agents, and opioids. These proposed updates involve measures to apply in both the inpatient and outpatient environments to track adverse drug events. The opportunity to submit written comments is now closed.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
Use of incompletely cleaned medical devices has been linked to health care–associated infections. Drawing from reports submitted to the FDA regarding infections related to reprocessed flexible bronchoscopes, this announcement offers recommendations to enhance the reliability of scope sterilization methods.
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. February 10, 2015. Publication No. NOT-HS-15-006.
This announcement highlights AHRQ funding opportunities to support continued research regarding effective tracking and identification of adverse incidents in ambulatory practice, with an emphasis on designing, refining, or validating epidemiological methods to augment the study of patient safety in ambulatory care.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
This announcement reveals the new National Patient Safety Goal for 2012, which aims to reduce catheter-acquired infections in hospitals.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 21, 2011.
This announcement reports the recall of several mislabeled products, including the commonly used anticoagulant warfarin.
Washington, DC: National Quality Forum; June 13, 2011.
This publication announces the 2011 National Quality Forum update of 2010 never events. The opportunity to provide open comment of the 29 serious reportable events, which includes 4 new events, has now passed.
Horsham, PA. Institute for Safe Medication Practices.
These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2019–2020 fellowships is now closed.
Washington, DC: National Quality Forum; September 2009.
This announcement provides background on the proposed 2010 effort to revise and expand the National Quality Forum list of never events.
Agency for Healthcare Research and Quality. Fed Register. September 2, 2009;74:45457-45458.
This announcement and accompanying Web site provide version 1.0 of the standardized guidelines for health care agencies to voluntarily report patient safety and health care information. Empowered by the Patient Safety and Quality Improvement Act of 2005, AHRQ-funded Patient Safety Organizations will analyze and organize the data.