Narrow Results Clear All
- Communication between Providers 7
- Culture of Safety 4
- Education and Training 11
- Error Reporting and Analysis 8
- Human Factors Engineering 9
- Legal and Policy Approaches 19
- Quality Improvement Strategies 19
- Specialization of Care 1
- Technologic Approaches 4
- Device-related Complications 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 2
- Identification Errors 2
- Interruptions and distractions 1
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 19
- MRI safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 2
- Transfusion Complications 1
- Surgery 1
- Nursing 2
- Pharmacy 15
- Health Care Executives and Administrators 35
Health Care Providers
- Nurses 6
Non-Health Care Professionals
- Media 6
- Patients 8
- Africa 1
- Asia 1
- Australia and New Zealand 1
- Central and South America 1
- Europe 3
- Canada 2
- United States of America 56
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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.
Joint Commission. March 12, 2018.
The Eisenberg Award honors individuals and organizations who have made unique and sustained contributions to the work of patient safety and quality improvement. The 2017 honorees are Dr. Thomas Gallagher; Children's Hospitals' Solutions for Patient Safety; and LifePoint Health's National Quality Program, Brentwood, Tennessee. The awards were presented at the National Quality Forum annual conference on March 12, 2018 in Washington, DC.
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.
Horsham, PA: Institute for Safe Medication Practices; 2017.
High-alert medications have the potential to cause substantial patient harm if administration mistakes occur. This assessment tool will enable organizations across a range of care environments to determine opportunities for improvement in 11 high-alert medication categories. In addition, the tool provides an opportunity for organizations to submit their data anonymously to a national data collection effort led by the Institute for Safe Medication Practices to define the current state of high-alert medication practices in health care. The data submission process is now closed.
Horsham, PA: Institute for Safe Medication Practices; August 24, 2017.
Institute for Safe Medication Practices.
Horsham, PA: Institute for Safe Medication Practices; January 11, 2017.
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.
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 process for the 2017–2018 year is closed.
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.
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.
Oakbrook, IL: Joint Commission; March 4, 2015.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2014 honorees are Mark L. Graber, MD, the American College of Surgeons National Surgical Quality Improvement Program, and North Shore-LIJ Health System in New York. The awards were presented at the National Quality Forum's annual conference on March 23, 2015, in Washington, DC.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. August 6, 2014. PA-14-311; PA-14-312; PA-14-313.
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.
London, UK: Health Foundation. May 9, 2014.
The Great Ormond Street Hospital Foundation NHS Trust received the 2014 Berwick Patient Safety Team Award for their project "Pursuing Zero by Building Sustainable Foundations for Safety," which applied recommendations generated in response to the Francis report. The program introduced a daily questionnaire for parents and patients about problems related to medication errors, equipment, communication, or organization of care, which was then reviewed with a nurse to immediately address concerns.
Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. February 18, 2014.
This announcement describes concerns related to incorrect information provided by a medication history service. Providers using Surescripts are encouraged to investigate and confirm medication dosages in electronic medical records that seem inappropriate.
Joint Commission. January 27, 2014.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2013 honorees are Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health, from Minnesota; Anthem Blue Cross, National Health Foundation, Hospital Association of Southern California, Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, from California; Vidant Health, of North Carolina; and Gail L. Warden, in Michigan. The awards were presented at the National Quality Forum's Annual Conference on February 13, 2014, in Washington, DC.
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.