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1. CDC generally met its inspection goals for the federal select agent program: however, opportunities exist to strengthen oversight

2. HRSA helped health centers with elevated risks and can continue to take additional steps

3. Latex: a lingering and lurking safety risk

6. Oral medications inadvertently given via the intravenous route

7. Patient-to-patient aggression in the inpatient behavioral health setting

8. Omission of high-alert medications: a hidden danger

9. Oral anticoagulants: a review of common errors and risk reduction strategies

11. Missed respiratory therapy treatments: underlying causes and management strategies

12. Newborns pose unique identification challenges

13. Prescribing errors that cause harm

14. Process assessment is key to prevention of certain ophthalmology events

26. Creating a culture for innovation and risk taking in transformative times

27. Frequent monitoring and behavioral assessment: keys to the care of the intoxicated patient

28. Safe health care for all patients: Pennsylvania Patient Safety Authority annual report : 2016

29. Design considerations and pre-market submission recommendations for interoperable medical devices: guidance for industry and Food and Drug Administration staff

30. Veterans' health care: limited progress made to address concerns that led to high-risk designation : testimony before the Committee on Veterans' Affairs, U.S. Senate

31. How portfolios evolve after retirement: the effect of health shocks

35. Medication errors in outpatient hematology and oncology clinics

36. Warming blankets and patient harm

37. Use of serological tests to reduce the risk of transmission of Trypanosoma cruzi infection in blood and blood components

38. Adverse drug events with HYDROmorphone: how preventable are they?

39. Beyond the bundle: reducing the risk of central line-associated bloodstream infections

40. Clostridium difficile infections in nursing homes

41. Connecting remote cardiac monitoring issues with care areas

43. Care at discharge: a critical juncture for transition to posthospital care

44. Hemodialysis administration: strategies to ensure safe patient care

46. Improving the safety of the blood transfusion process

47. Medication errors in the emergency department: need for pharmacy involvement?

48. Managing patient access and flow in the emergency department to improve patient safety

49. Increasing influenza and pneumonia vaccination rates in long-term care

51. Safe intrahospital transport of the non-ICU patient using standardized handoff communication

53. Uterine perforation associated with minimally invasive gynecologic procedures

55. Preventing corneal burns during phacoemulsification

56. Timely treatment of stroke symptoms in the emergency department may improve outcomes

59. Pressure ulcers: new staging, reporting, and risk reduction strategies

60. Prevention of inadvertent perioperative hypothermia

61. Sterile water should not be given "freely"

62. Medication errors associated with documented allergies

64. Hand hygiene practices and the use of alcohol-based sanitizers

70. Medicare and Medicaid: CMS needs to fully align its antifraud efforts with the fraud risk framework : report to Congressional addressees

71. Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania

73. Healthcare worker fatigue: current strategies for prevention

74. An analysis of reported adverse drug reactions

75. Balancing family bonding with newborn safety

76. Improving care for patients with autism spectrum disorder in the acute care setting

77. Hospital-acquired pressure ulcers remain a top concern for hospitals

78. Family members advocate for improved identification of patients with dementia in the acute care setting

79. A conceptual framework for improving isolation awareness in Pennsylvania acute care hospitals

82. Analysis of reported drug interactions: a recipe for harm to patients

83. National biodefense strategy: additional efforts would enhance likelihood of effective implementation : report to Congressional committees

85. Federal research: NIH could take additional actions to manage risks involving foreign subrecipients : report to congressional requesters

92. Drug shortages: shortchanging quality and safe patient care