Best practices regarding compounding sterile preparations and patient safety ranging from fentanyl patches to breast implants.
Newsletter
Pharmacy Compounding Safe Practice Recommendations
Aug 31, 2013
Patient Safety Alert 14: Pharmacy Compounding Safe Practice Recommendations (PDF)
The AMC PSO recently held its follow up Medication Safety Task Force collaborative convening session to discuss the best practices regarding the issues within compounding sterile preparations and patient safety that were brought up in the first meeting.
Alert
One retrospective study examining breast implant lawsuits (O’Brien C, 1999) detailed how plaintiffs used individual legal claims against doctor defendants to push these physicians into quick and lower monetary settlements so larger, and more expensive, future lawsuits against the manufacturers could be financed.
- Plaintiffs have also won recent combined lawsuits against physicians and manufactures over medication and medical device malfunctions (Gallegos A, 2013): In 2012, a jury ordered a physician and manufacturer to pay $5.5 million to a mesh implant plaintiff. Jurors found the manufacturer 60% at fault and the surgeon 40% at fault. Multiple lawsuits regarding flawed mesh implants are currently in motion.
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
No Surgical Items Left Behind
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While the occurrence is rare, Massachusetts reported rising rates of retained surgical items over the past several years.
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Patient & Visitor De-escalation
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Patient Safety Alert Issue 25: The AMC PSO convened a panel of safety leaders to review recent trends and discuss novel interventions to mitigate the risk for hospital workplace violence, especially from patients and visitors.
![Pharmacist holding medicine box and capsule pack in pharmacy drugstore.](/-/media/Project/Rmf/CRICO/1x1images/1x1_auto_2104.jpeg)
Medication Administration in the Ambulatory Setting
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Patient Safety Alert Issue 26: The AMC PSO convened a panel of nursing leaders to review risks in the medication delivery processes in the ambulatory setting and discuss potential interventions aimed at mitigating the risks associated with medication administration.
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Electronic Health Record Risks in the Emergency Department
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Establishing a Regional Registry for Neonatal Encephalopathy: Impact on Identification of Gaps in Practice
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Neonatal encephalopathy continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of CRICO. A neonatal encephalopathy registry was also established. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects.
Utilization of Electronic Health Record Sex and Gender Demographic Fields: A Metadata and Mixed Methods Analysis
News
CRICO Grants
This CRICO co-funded retroactive study published in the Journal of the American Medical Informatics Association analyzed the records of patients 18 years of age or older in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between 2018 and 2022. The study was important because "Sex and gender demographic data are widely viewed as essential to providing culturally responsive gender affirming care and facilitating research and public health interventions."
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Ambulatory Safety Nets: Protecting Providers and Promoting Safety with Systems to Reduce Delayed Cancer Diagnoses
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CRICO Grants
Ambulatory safety nets (ASNs) are person-centered programs that provide a highly reliable backup system for following up on abnormal test results when the standard follow-up process fails. Co-authored by CRICO’s Pat Folcarelli RN, MA, PhD, and Luke Sato, MD, this article about ASNs was featured in Inside Medical liability Online.
The Safety of Outpatient Health Care
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Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. This study looks at adverse events in outpatient settings.