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ISMP Survey on the Implementation 2018-2019 Targeted Medication Safety Best Practices for Hospitals.
Institute for Safe Medication Practices.
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.
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.
Horsham, PA: Institute for Safe Medication Practices; August 24, 2017.
Horsham, PA: Institute for Safe Medication Practices; January 11, 2017.
Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.
Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.
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.
Notice of Intent to Publish Funding Opportunity Announcements to Promote Implementation Science (R01) and Dissemination and Implementation Studies (R18).
Rockville, MD: Agency for Healthcare Research and Quality; October 25, 2016. AHRQ Publication No. NOT-HS-17-002.
Implementation science has been highlighted as a key component to achieve progress. This notice of intent from AHRQ provides information about two upcoming funding opportunities to support the adoption of implementation science in safety and quality improvement work. One (RO1) will help to refine and develop methods to assess implementation success and the other (R18) will support the dissemination of evidence-based patient-centered improvements.
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.
Joint Commission. April 7, 2016.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2015 honorees are Pascale Carayon, PhD; Premier, Inc.; and Mayo Clinic Hospital-Rochester. The awards were presented at the National Quality Forum's annual conference on April 7, 2016, in Washington, DC.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.
FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 4, 2016.
This announcement alerts prescribers to differences in two oral formulations of the same medication that can lead to dosing errors. The FDA suggests that clinicians specify dosage form, strength, and frequency on prescriptions for this drug to reduce the risk of patient harm and recommend that pharmacists follow up with prescribers if such information is missing.
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.
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.
FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor).
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.
Look-alike and sound-alike drug names can contribute to confusion and result in medication errors. To raise awareness of potential wrong-patient errors due to similarity between two proprietary names, this announcement describes near misses with the drugs at the prescribing and dispensing stage and suggests clinicians use the generic names for the medications to reduce risk of patient harm.
Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. June 30, 2015.
Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.
FDA cautions about dose confusion and medication errors for antibacterial drug Zerbaxa (ceftolozane and tazobactam).
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; May 20, 2015.
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.
Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. This announcement raises awareness of new packaging for existing medications that may cause confusion due to similarities in color and layout. Recommendations are outlined to prevent mistakes associated with use of these medications.