Patient safety is everybody's business. The information published in the Advisory is relevant for all clinicians and is intended to be distributed to as many individuals in healthcare facilities as possible.

Patients can offer key input into their own safety when given the opportunity, including rapidly identifying side effects or adverse events, ensuring that treatment is given, deciding on treatment, and helping to achieve accurate diagnosis.

The Patient Safety Authority strongly encourages facilities to consider adopting one or both of the following innovative programs: (1) "Stand Up for Patient Safety" and (2) "100,000 Lives Campaign."

A verbal order from the physician that includes all the necessary elements and is read back by the nurse for verification could reduce errors related to the verbal mode of prescribing.

Cardiac arrhythmias, although rare, can occur during electrohydraulic lithotripter procedures.

After an event is determined to be the result of ineffective communication, two salient points include (1) fewer intermediaries create fewer opportunities for misunderstanding and (2) the less that intermediaries understand about the message, the greater the chance for misunderstanding.

Event reports indicate that unlabeled bowls, basins, and cups (containing medications and solutions) continue to be a problem.

Two distinct patterns emerge from event reports involving eye surgery: (1) wrong-side surgery and (2) problems with intraocular lens implants.

Submitted event reports describing injuries to patients from the use of incompatible device parts make evident the need for awareness about compatibility of medical devices and associated accessories that require assembly before use.

Means to secure tracheal tubes are discussed after an event report describes a patient who self-extubated.

Many topical anesthetic sprays have been implicated in cases of methemoglobinemia, a serious and sometimes fatal adverse drug reaction.

Abbreviations and nonstandard dose designations are frequently misinterpreted, and they often lead to errors resulting in patient harm.

Patient injuries associated with seclusion and restraint can be a catalyst for improvement, including alternatives in care delivery for behavioral health patients.

Surgical preparation includes more than training and "time outs."