The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.
Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
This cohort study, conducted within a large health management organization (HMO), examined the frequency of adverse drug events (ADEs) that were attributable to errors elderly patients made in handling their medications. Nearly one-quarter of ADEs... Read More
This retrospective cohort study of more than 1200 Medicare enrollees determined that adverse drug events (ADEs) increase the health care costs associated with such events. Building on a previous study in the same patient population, investigators... Read More
Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range... Read More
This study analyzed more than 1500 adverse drug events and discovered that nearly 28% were preventable. Investigators studied a large population of Medicare enrollees in a single multispecialty group practice capturing events through a number of... Read More
Hospitalized children may be particularly vulnerable to medication errors given differences in dosing and monitoring of medications. This study, conducted at five California children's hospitals, used several medication error detection methods to... Read More
Medication errors are prevalent in inpatient care. This narrative review compared medication errors in neonatal care with those across hospitalized pediatric, adult, and elderly patients. Common types of errors among hospitalized neonatal patients... Read More
This systematic review found that incidence rates of medication errors in primary care ranged between 1% and 90% across included studies, suggesting that further research is needed to identify the true incidence. The authors identified most errors in... Read More
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) coordinates a nationwide campaign for medication error reporting and prevention. They promote recommendations broadly to colleges, schools, and state and national... Read More
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication... Read More
This commentary suggests strategies for improving prescribing safety, including linking pharmacy and laboratory data through health information technology.
This scoping review discussed how organizational and professional culture influences medication safety practices. The authors reviewed over 40 articles and identified four themes influencing medication safety: (1) professional identity, (2) fear of... Read More
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found... Read More
This study convened focus groups that included the public, patients, and caregivers to define a framework for medication safety problems. Participants described the importance of factors such as communication, supply of medications, health... Read More
Use of color-coded medications resulted in a reduction in medication errors in simulated pediatric emergency department scenarios.
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85... Read More
This mixed-methods study of patients, caregivers and healthcare professionals explores how patient-held medication lists (such as paper medication lists, medication diaries, or apps) can support patient safety. Patient-held lists can improve... Read More
Swayne T. London, UK: National Patient Safety Agency, The Helen Hamlyn Research Centre; 2007.
This illustrated report provides guidelines for the packaging of pharmaceuticals along with an information design checklist for minimizing medication error.
This Web site provides information for providers and patients to reduce risks related to adverse drug events, including links to fact sheets, research, and government initiatives.
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization promoting health improvement by advancing the quality and value of health care. Current IHI initiatives include a white paper collection, an international conference... Read More
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major... Read More
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order... Read More
The Institute for Safe Medication Practices (ISMP) is a nonprofit organization whose focus is to help health care practitioners understand medication error from a systems perspective, collect reports of errors, and disseminate ... Read More
Strategies to prevent medication errors are a continuing focus of ongoing safety initiatives. This guidance outlines factors to consider when creating drug products to reduce design-associated medication errors.
In light of the current opioid crisis, the use of opioids to manage noncancer-related chronic pain in the ambulatory environment has been targeted for improvement. This AHRQ-funded initiative offers a six-element multidisciplinary redesign approach... Read More