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 http://www.preventinghais.com.

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.