CPS Safety Watch/Alert – Medication Shortages

Medication Shortages:

  • Adversely affect drug therapy
  • Can cause complications in medical procedures
  • Contribute to medication errors
  • Create frustration for providers & patients


  • Validate details of shortage & check with suppliers
  • Determine stock on hand
  • Determine purchase history & true use
  • Estimate time until shortage impacts agency & length of shortage
  • Identify alternative drug and sources


  • Communicate with staff details regarding shortage:
    • Specific drug & effective date/length of shortage
    • Alternative drugs/concentrations
    • Temporary guidelines & processes
  • Utilize teamwork to identify susceptible patient population
  • Review the 5 “R’s” of medication administration (Right medication, Right dosage, Right route, Right patient, Right time)
  • Implement 2-person medication read-back or cross-check policy



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Addressing The Opioid Crisis

Sometimes health care providers do not recognize the ever-growing opioid problem as one they should address.  Think again!  Read Health Affair’s blog with suggested resources that providers and the community can use.  Together we can address this!

PSO Lessons Learned: Medication Errors

Annually, the majority of events submitted to the Center for Patient Safety’s PSO result in no harm to the patient, however, there is a steady increase in events reported to the PSO which supports continued learning. With nearly 35,000 events from healthcare organizations, medication events continue to be the highest reported event type, followed by falls.

Accurate medication reconciliation is a challenge. There are near misses and patient events reported to the Center’s database related to errors which occurred because the reconciliation process was either skipped or not done properly. In one case, a patient received another patient’s medications in error because they had been entered in the wrong medical record. Due to the patient’s underlying renal failure, the incorrect medications exacerbated the condition, resulting in death.


Streamline the reconciliation process as much as possible, but ensure that staff understand the importance of completing it accurately for every patient and  follow the “5 Rs”:

  • Right Medication
  • Right Patient
  • Right Time
  • Right Dosage
  • Right Route of Administration


PSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details. The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing, and proactively preventing future harm, costs, and liability exposure.

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Medication Reconciliation Interventions in Transitions of Care – AHRQ Webinar Recording Available

A recording of AHRQ’s May 20 CE Webinar exploring hospital-based medication reconciliation intervention to reduce medication errors in transitions of care is now available. The webinar shares successful strategies such as pharmacist-led processes to prevent medication error and adverse drug events.  Also available is an AHRQ report on the topic and the MATCH toolkit, a step-by-step guide to improve the process that are also discussed on the Webinar.

Medication Reconciliation Toolkit Available from AHRQ

The Agency for Healthcare Research and Quality has released a toolkit  “Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.”   The toolkit is designed to facilitate the reduction of patient harm due to adverse drug events or medication errors.   AHRQ suggests the following advantages:

  • Promotes compliance with The Joint Commission’s National Patient Safety Goal for maintaining and communicating accurate patient medication information
  • Can lead to better care transitions and fewer unnecessary readmissions by helping to ensure patients receive the right medication in the right dose at the right time
  • Provides a framework to capture complete, accurate medication information through electronic health records (EHRs)
  • Enables building a medication reconciliation process from scratch or redesigning an existing process

The toolkit is designed to help acute care and post-acute care facilities evaluate and improve their current medication reconciliation process.     Check it out today!


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.