PA-PSRS continues to receive recognition as an innovative approach to promoting patient safety and reducing medical errors.

Extravasation of radiologic contract media accounts for a substantial proportion of infiltration reports submitted through PA-PSRS.

Approximately one in four medication error reports submitted through PA-PSRS involves a high-alert medication.

Reminders are an essential part of monitoring activities in complex environments such as healthcare. Incorporating checklists as reminders into the healthcare environment can yield beneficial results, such as improved compliance with best practices in clinical settings.

Most surgical fires involve electrosurgery and begin when the electrosurgical unit is activated in an oxygen-enriched environments.

Use of transdermal medication systems can make drug administration more convenient and increase compliance, but their use is not without risk.

Event reports demonstrate (1) that the time out can be useful defense against wrong-site surgery and (2) problems with implementing the time out may limit its benefits.

Bed exit alarms can be an important component of fall prevention programs, but the technology may not always be used effectively.

Online resources for fall prevention programs include the Premier Safety Institute, the Southern California Evidence-Based Practice Center, and the National Guideline Clearinghouse.

The University of Pittsburgh Medical Center wins a 2004 Eisenberg award in recognition of its efforts to resolve problems related to falls and nosocomial infections.

A published systematic review finds that there is considerable support for disclosure of medical errors among physicians and the public, but that errors are nevertheless not disclosed.

A Missouri medical center publishes the results of its effort to change its punitive culture into a just and fair one.