Patient Safety Alerts Library
AMC PSO Patient Safety Alerts and are short PDF documents that summarize a topic covered by our members. New editions are free and will be available here.
Patient Safety Alert

AMC PSO makes patient safety learnings available to the public as part of CRICO’s ongoing commitment towards improving patient safety across the continuum of care. Some of these learnings are in a newsletters called the AMC PSO Patient Safety Alerts and are short PDF documents that summarize a topic covered by our members. New editions are free and will be available here. We will also include learnings from a national convening called the National Safe Table.

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More AMC PSO Publications


March 2023–Long Stay Critical Care Patients Boarding in the Emergency Department

Issue 31: A review of the care of critically ill patients who are boarded in the Emergency Department. Patient safety risks and mitigation strategies associated with extended boarding of patients awaiting an intensive care unit (ICU) bed.



December 2021–Informed Patient Refusal in Virtual Care
Issue 30: Ways to clearly communicate the risks of refusal of an in-person visit to my patient and maintain a therapeutic alliance

December 2021–Advisory: Detecting and Reporting Patient Safety Risks in Virtual Care Delivery
National Safe Table: a first step in providing nation-wide collaboration to develop an effective process to develop and report on adverse and near-miss events in virtual care



December 2019–The Necessity of Peer Support
Issue 29: Family members receive strong support from the hospital when an adverse event occurs. What about your staff?



August 2017 – Patient Identification Risks and the Intersection of Electronic Health Records
Issue 28: Identification errors occur for myriad reasons and since no singular solution exists, a multi-pronged approach for safer patient identification is essential.



December 2016–Electronic Health Record Risks in the Emergency Department
Issue 27: When EHR workflows do not align with ED clinical workflows, common workarounds erupt, increasing the potential for error.

December  2016–Medication Administration in the Ambulatory Setting
Issue 26: The nature of ambulatory health care often creates scenarios where providers and their staff are confronted with tensions inherent to these settings, including high patient volumes coupled with a need for operational expediency.

March 2016–Patient & Visitor De-escalation
Issue 25: Due to the unpredictable nature and potentially serious outcomes related to workplace violence events, hospitals are now working to develop more comprehensive security protocols and training programs.



December 2015 – Periprocedural Management of Anticoagulation Therapy
Issue 24: Patient Safety professionals discuss the contributing factors often associated with this medication event type, and the strategies to proactively mitigate this risk.

April 2015–Patient Falls
Issue 23: Nursing leaders review recent trends, evaluate the current literature, and discuss novel interventions aimed at mitigating the risk regarding patient falls.



December 2014–Failure to Rescue

Issue 22: Insufficient patient monitoring and failure to rescue.

November 2014–Results Management Report

Issue 21: Test results follow-up and management issues.

October 2014–Diagnosis and Treatment of Ischemic Stroke 
Issue 20: Challenges in assessing and treating patients presenting with symptoms related to ischemic stroke, and, in particular, vertebrobasilar stroke.

May 2014–Missed and Delayed Diagnoses in the ED
Issue 18: Study some of the problems that can impede a prompt and accurate diagnosis.



December 2013–Obstructive Sleep Apnea - Management Considerations

Issue 19: Patient safety issues relevant to postoperative management of sleep apnea.

August 2013–Test Result Notification

Issue 15: Current issues and possible solutions and propagate the natural progression of CRICO’s established mission of helping health care providers turn credible data into effective action.

August 2013–Pharmacy Compounding Safe Practice Recommendations

Issue 14: Best practices regarding the issues within compounding sterile preparations.

July 2013–Pharmacy Compounding

Issue 13: Current issues in compounding sterile preparations.

July 2013–Harvard Surgical Chiefs Endorse Automated Detection Technology for Retained Foreign Objects

Issue 12: Analysis of patient safety events in the surgical setting has identified emerging technologies and new strategies to complement existing patient safety protocols.

June 2013–Delayed Diagnosis 
Issue 11: Practices identified to reduce risks resulting from missed diagnoses or delayed diagnoses in the ED.



December 2012–Sepsis: Early Recognition and Treatment

Issue 10: OB-related malpractice claims along with real-time root cause analysis information reveals trends and emerging risks. Part II

December 2012–Patient Safety in Labor and Delivery: Managing Complex Conditions in a Complex Environment

Issue 9: OB-related malpractice claims along with real-time root cause analysis information reveals trends and emerging risks. Part I.

August 2012–Medication Safety in the ICU

Issue 8: A review of adverse drug events in the ICU setting has identified several risks and vulnerabilities.

June 2012–Risks Associated with Interventional Procedures in the Ambulatory Setting 
Issue 7: Address the risks associated with interventional procedures in the ambulatory setting.

May 2012–RCA Information Exchange – PCA Pump Alarm Update
Issue 6: A review of safety issues involving ambulatory pumps used to administer patient controlled analgesia (PCA).



December 2011–Surgical Fires: Electrosurgical Cases 
Issue 5: Analysis identified three surgical fire interventions: prevention, response, and training.

November 2011–PCA Pump Alarm Safety Concerns 
Issue 4: Many issues surround new PCA pumps.

October 2011–Programmable Medical Equipment Risks and Interventions 
Issue 3: Factors that can contribute to risks associated with programmable medical devices.

August 2011–Risks of Programmable Medical Equipment 
Issue 2: Several recommendations to decrease risks related to equipment complexity and user fallibility.

July 2011–Wrong Site Surgery  
Issue 1: Interventions to address the factors that can contribute to wrong-site surgery.


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