In the world of risk mitigation, it’s not often that there’s a straightforward solution. So, when there is, it’s worth some serious consideration. In the case of error-prone medication dosage abbreviations, it’s as easy as this: don’t use them (available to the public for a limited time).  Use of medication dosage abbreviations is a long

July 22, 2015 - 1:25 pm

The unfortunate death of a 55 year old man at the University of Vermont Medical Center resulting from a five-fold overdose of Ketamine leads to many lessons learned for safe medication policies, medication administration and timeliness of action plan implementation for hospitals and EMS: Lesson #1 – Consider the danger of using multi-dose vs. single-dose

July 7, 2015 - 4:09 pm

The National Alert Network recently issued an alert based on a fatal medication error where a nurse confused fluid drams with mL.  While the healthcare system bases most of its medication on the metric system, many measuring cups utilized for liquid medication not only still have drams listed, but also ounces listed.  Harm could be

The Center for Patient Safety and others discuss concerns and benefits of the delay in the PSO participation rule requirement of the Affordable Care Act. While the delay allows additional consideration on how to implement the rule, are current Medicare requirements sufficient to move patient safety improvement forward? Will the delay stifle the expanded sharing,

September 6, 2013 - 11:00 am

Henry Ford Health System shares seven components of a friendly medical error reporting environment:  leadership support, appropriate infrastructure, anonymous reporting, error disclosure to patients and families, communication, just culture, and continual improvement of its patient safety culture.  Their successes were recognized in 2011 when they received the Malcolm Baldrige National Quality Award and the John

July 11, 2013 - 1:39 pm

Think a wrong site surgery can’t happen at your hospital or surgicenter?  Every surgery or invasive procedure is at risk!  The Joint Commission recently shared 5 tips to reduce the chances: 1.  Evaluate your entire operative process to identify areas of risk 2.  Standardize your scheduling process; do not allow the use of abbreviations 3. 

March 11, 2013 - 10:46 am

SorryWorks! has been promoting transparency and disclosure since 2005 and has outstanding tools to support that effort.  But often we struggle with setting patient expectations and opening up communication from the patient’s side.  SorryWorks! has developed a letter that physicians and other providers can use as a temple for their own handout  to open a