Patient Safety Alerts Quick List
Patient Safety Alert
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Patient Safety Alert Guidance to Reduce the Risk of Retained Surgical Items:  Best practices to reduce retained surgical items (RSI).


Cybersecurity and Recovery: New online threats put health care systems at risk every day. These cybersecurity recommendations contain strategies to deal with ransomware or denial service and more.


Long Stay Critical Care Patients Boarding in the Emergency Department: A review of the care of critically ill patients who are boarded in the Emergency Department. Experts recommend ways to recognize patient safety risks and employ mitigation strategies associated with extended boarding of patients awaiting an intensive care unit (ICU) bed.


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


National Safe Table Advisory: Detecting and Reporting Patient Safety Risks in Virtual Care Delivery: 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.


The Necessity of Peer Support: See a systematic approach to supporting hospital-based clinicians and staff in the wake of a traumatic event, whether that event be in the context of care delivery or a clinician or staff member’s personal life.


Patient Identification Risks and the Intersection of Electronic Health Records: Learn strategies for safer patient identification.


Electronic Health Record Risks in the Emergency Department: Learn to identify significant areas of concern and to explore potential mitigation strategies.


Medication Administration in the Ambulatory Setting: Review risks in the medication delivery processes in the ambulatory setting and discuss potential interventions aimed at mitigating the risks associated with medication administration.


Patient & Visitor De-escalation: 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.


Anticoagulation: The AMC PSO recently convened to discuss periprocedural management of anticoagulation therapy, a high-risk area and important patient safety issue, the contributing factors often associated with this medication event type, and the strategies to proactively mitigate this risk.


Patient Falls: Current peer-reviewed literature has consistently demonstrated that patient falls in clinical settings are commonly reported adverse events. These observations are also reflected in data analyzed by the Academic Medical Center Patient Safety Organization (AMC PSO). Literature has shown that patient falls have also been correlated with increased length of hospital stays, transfers to higher levels of care, discharges to higher levels of skilled nursing facilities (rather than to home), and an overall increase to the cost of care. In response to this ongoing safety concern, the AMC PSO convened a panel of nursing leaders to review recent trends, evaluate the current literature, and discuss novel interventions aimed at mitigating the risk for this type of adverse event.


Failure to Rescue: The Academic Medical Center Patient Safety Organization (AMC PSO) has observed a growing portion of its submissions to be related to insufficient patient monitoring and failure to rescue. To gain a better understanding of failure to rescue’s causes and potential solutions, the AMC PSO assembled a panel of subject matter experts to review data, literature, and their own experiences with these types of events.


Results Management: Continuing deliberations on test results management begun in 2013, the Academic Medical Center Patient Safety Organization (AMC PSO) gathered a panel of ambulatory risk management and  patient safety experts to address this persistent issue. Related literature shows that 25% of all outpatient medical errors can be attributed to the test-results follow up process.


Diagnosis and Treatment of Ischemic Stroke: The AMC PSO recently convened subject matter experts and ED clinical leaders to address these challenges in assessing and treating patients presenting with symptoms related to ischemic stroke and, in particular, vertebrobasilar stroke.


Obstructive Sleep Apnea–Management Considerations: The Academic Medical Center Patient Safety Organization (AMC PSO) recently convened its member opinion leaders from multiple disciplines to share their expertise regarding patient safety issues relevant to postoperative management of sleep apnea. Participants analyzed a representative case and discussed existing guidelines, strategies, and emerging technologies that complement existing management protocols.


Missed and Delayed Diagnoses in the ED: The AMC PSO recently convened Emergency Medicine Leaders to share their expertise and opinions regarding patient safety issues relevant to the Emergency Department (ED) setting. Participants discussed case studies, as well as emerging technologies and new strategies that are now available to complement existing patient safety protocols aimed at reducing ED adverse events, specifically those associated with delayed diagnosis.


Maternal Mortality
Not available


Brachial Plexus Injury
Not available


Test Result Notifications 
The Academic Medical Center Patient Safety Organization (AMC PSO) recently held a collaborative convening session of its Ambulatory Patient Safety Leaders. Key opinion leaders from member outpatient medicine divisions and patient safety departments gathered to offer and share their expertise and opinions regarding the most current issues in Ambulatory Care, specifically test result notification.


Pharmacy Compounding Safe Practice Recommendations
In follow-up to its first Medication Safety Task Force (MSTF) Collaborative, the Academic Medical Center Patient Safety Organization (AMC PSO) held an additional convening session. Key opinion leaders from member regional pharmacies and health care centers gathered to discuss best practices regarding compounding sterile preparations and patient safety, which had been generated directly from a MSTF held earlier in the year.


Pharmacy Compounding

The Academic Medical Center Patient Safety Organization (AMC PSO) recently held its first Medication Safety Task Force (MSTF) collaborative convening session. Key opinion leaders from member pharmacy departments gathered to offer their expertise and opinions regarding the most current issues in compounding sterile preparations and patient safety.


Harvard Surgical Chiefs Endorse Automated Detection Technology for Retained Foreign Objects

The Academic Medical Center Patient Safety Organization (AMC PSO) recently performed an analysis of patient safety events in the surgical setting. As part of this analysis, the AMC PSO convened key opinion leaders in surgery to elicit their expertise and opinions specific to the issue of retained surgical items (sponges, instruments, needles, and tools) collectively known as Retained Foreign Objects (RFOs). The goal of this convening session was to develop best practice recommendations to mitigate the risk of RFOs in the surgical setting.


Delayed Diagnosis
The Academic Medical Center Patient Safety Organization (AMC PSO) held a Collaborative convening session for Emergency Department (ED) Leaders from member regional hospitals to offer their expertise and opinions regarding issues relevant to the ED setting. An analysis of delays in diagnosis in the ED setting was discussed to illustrate risks and vulnerabilities specific to this clinical area.


Sepsis: Early Recognition and Treatment 

The AMC PSO recently performed an in-depth review of the risks associated with sepsis, with a particular focus on this diagnosis in the surgical population. Sepsis is a leading cause of mortality in the US. Hospitalization rates related to sepsis (as either a primary or secondary diagnosis) rose 70% between 2000 and 2008.


Patient Safety in Labor and Delivery

Labor and Delivery is a fast-paced, complex, clinical environment where emergencies can arise without warning. As such, staff must adopt a proactive approach to patient safety and be continuously vigilant in their ability to respond quickly and effectively to various clinical scenarios in this dynamic environment.


Medication Safety in the ICU
Medication use is the most common form of medical treatment in the intensive care unit (ICU) setting. Adverse events related to medication use are also the most frequent type of ICU adverse events.


Risks Associated with Interventional Procedures in the Ambulatory Setting
The AMC PSO has highlighted some potential risks contributing to wrong patient interventional procedures in the ambulatory setting and has identified safety strategies to mitigate these risks.


RCA Information Exchange – PCA Pump Alarm Update
This highlights a new secure, web-based tool will be used for transmission of standardized RCA data as well as new safety issues involving ambulatory pumps used to administer patient controlled analgesia (PCA).


Surgical Fires: Electrosurgical Cases
The AMC PSO members, comprised of safety and risk leaders and their subject matter experts, met in November to discuss a surgical fire that arose during the use of electrosurgical cautery. They noted that although these events are rare, they often have disastrous consequences for patients and the surgical team.


PCA Pump Alarm Safety Concerns
In November, a triggered ad hoc convening session was held at the request of an AMC PSO member. Having met specific criteria, this case was brought forward for discussion due to important safety issues involving an ambulatory pump.


Programmable Medical Equipment Risks and Interventions
In September, the AMC PSO continued its analysis of the risks associated with programmable medical devices. These risks had been illustrated in a recent OR case involving changes made to an anesthesia machine’s default settings during routine vendor servicing.


The Risks of Programmable Medical Equipment
An ad hoc meeting of the AMC PSO was held to address anesthesia machine safety concerns identified by one of its members.



Wrong Site Surgery
Wrong-site (including wrong side) surgeries/procedures account for a relatively small portion of surgery-related malpractice cases, but they almost always represent events that are impossible to justify (or defend). The National Quality Forum defines wrong-site cases as “never events” and CMS will no longer reimburse for these cases.

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