Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

As colleges and schools of pharmacy develop core courses related to patient safety, course-level outcomes will need to include both knowledge and performance measures. Three key performance outcomes for patient safety coursework, measured at the course level, are the ability to perform root cause analyses and healthcare failure mode effects analyses, and the ability to generate effective safety communications using structured formats such as the Situation-Background-Assessment-Recommendation (SBAR) situational briefing model. Each of these skills is widely used in patient safety work and competence in their use is essential for a pharmacist's ability to contribute as a member of a patient safety team.

Patient Safety and Quality Improvement Act of 2005.

OBJECTIVE: To review Public Law (PL) 109-41-the Patient Safety and Quality Improvement Act of 2005 (PSQIA)-and summarize key medication error research that contributed to congressional recognition of the need for this legislation. DATA SOURCES: Relevant publications related to medication error research, patient safety programs, and the legislative history of and commentary on PL 109-41, published in English, were identified by MEDLINE, PREMEDLINE, Thomas (Library of Congress), and Internet search engine-assisted searches using the terms healthcare quality, medication error, patient safety, PL 109-41, and quality improvement. Additional citations were identified from references cited in related publications. STUDY SELECTION AND DATA EXTRACTION: All relevant publications were reviewed. Summarization of the PSQIA was carried out by legal textual analysis. DATA SYNTHESIS: PL 109-41 provides privilege and confidentiality for patient safety work product (PSWP) developed for reporting to patient safety organizations (PSOs). It does not establish federal mandatory reporting of significant errors; rather, it relies on existing state reporting systems. The Act does not preempt stronger state protections for PSWP. The Agency for Healthcare Research and Quality is directed to certify PSOs and promote the establishment of a national network of patient safety databases. Whistleblower protection and penalties for unauthorized disclosure of PSWP are among its enforcement mechanisms. CONCLUSIONS: The Act protects clinicians who report minor errors to PSOs and protects the information from disclosure, but providers must increasingly embrace a culture of interdisciplinary concern for patient safety if this protection is to have real impact on patient care.

Over-the-counter availability of Plan B emergency contraception: further discussion and commentary.

The controversy surrounding the potential switch of the Plan B emergency contraceptive therapy from prescription to over-the-counter status has been unprecedented. Regulatory, professional, and societal aspects of this issue have been discussed recently and will no doubt continue to be debated. In this editorial, members of the Medicine, Law, and Ethics panel of The Annals of Pharmacotherapy's Editorial Board offer a sampling of viewpoints touching on varying aspects of the controversy. Readers may wish to consider the ramifications of their professional decisions in this and similar situations in advance of having to make such decisions.