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- Audiovisual 3
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- Tools/Toolkit 10
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- Communication Improvement 12
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- Education and Training 29
- Error Reporting and Analysis 20
- Human Factors Engineering 15
- Legal and Policy Approaches 20
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- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
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- Medical Complications 10
- Medication Errors/Preventable Adverse Drug Events 31
- MRI safety 5
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- Internal Medicine 27
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 53
- United States Federal Government 56
Search results for "Medicine"
- Press Release/Announcement
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.
Society to Improve Diagnosis in Medicine.
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.
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.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.
This announcement highlights Agency for Healthcare Research and Quality funding opportunities for health services research to assess local, state, and system-level policy to address the opioid crisis, evaluate interventions to minimize opioid misuse, and understand the rapid increase in opioid-related hospitalizations.
Institute for Safe Medication Practices.
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.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Results from this survey will inform the revision of a high-alert medication list used to raise awareness about drugs that have heightened potential to cause patient harm if used incorrectly.
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.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Drug Enforcement Administration. October 26, 2019.
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.
NHS Improvement. London, UK: National Health Service.
Organizational processes to investigate adverse care incidents play an important part in generating the learning needed for improvements. This announcement sought multidisciplinary insights regarding how to revise the Serious Incident Framework (2015), currently used by the National Health Service, to enhance reporting and investigation processes.
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.