1. Section Editor(s): Kennedy, Maureen Shawn MA, RN

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After actor Dennis Quaid's newborn twins were given overdoses of heparin in November 2007, medical errors were back in the spotlight. A Joint Commission survey of data from 1997 through 2007 showed 446 medication-related sentinel events (unexpected incidents causing or risking death or serious injury); 32 involved anticoagulants whose use was problematic for reasons such as improper dosage and inadequate monitoring. And with hospital-acquired infections from methicillin-resistant Staphylococcus aureus and Clostridium difficile continuing to plague hospitals, medical and epidemiologic organizations are compiling strategies to fight them. Patient information sheets and a link to the free collection of provider recommendations, funded by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, are available at


The Joint Commission is addressing other issues that can affect patient safety. Joint Commission-accredited hospitals now must adopt codes of conduct that define and manage bullying, intimidation, and uncooperative behavior among staff. The development of disciplinary protocols for offenders is also encouraged.