Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

Matthew Grissinger

Commentary

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

December 19, 2018

Grissinger M. P T. 2018;43(11):645-666.

View more articles from the same authors.

Although best practices that support safe and reliable medication therapy exist, they are not uniformly embedded in care delivery. This three-part series discusses medication safety risks and highlights topics such as wrong-patient orders, inadequate patient understanding of drug instructions, and poor lighting.

PubMed citations

Free full text: Part 1

Free full text: Part 2

Free full text: Part 3

Related Resources From the Same Author(s)

'Inattentional blindness': what captures your attention?

November 21, 2012

Physical environments that promote safe medication use.

August 29, 2012

That's the way we do things around here! Your actions speak louder than words when it comes to patient safety.

June 18, 2014

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

April 28, 2010

Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

May 7, 2008

Driving out errors.

April 27, 2011

Making it easier to do the right thing: a modern communication QI agenda.

August 8, 2012

Patient falls while under supervision: trends from incident reporting.

July 5, 2023

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Can your nurses stop a surgeon?

September 26, 2007

Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children's hospitals.

June 11, 2008

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

From tokenism to empowerment: progressing patient and public involvement in healthcare improvement.

April 13, 2016

"Never events" and the quest to reduce preventable harm.

June 3, 2015

Improving ambulatory patient safety: learning from the last decade, moving ahead in the next.

December 21, 2011

The unmeasured quality metric: burn out and the second victim syndrome in healthcare.

August 7, 2019

Closing the disclosure gap: medical errors in pediatrics.

March 27, 2019

Latent bias and the implementation of artificial intelligence in medicine.

July 15, 2020

Managing clinical failure: a complex adaptive system perspective.

May 30, 2007

Health literacy and communication quality in health care organizations.

November 24, 2010

Value of human factors to medication and patient safety in the intensive care unit.

July 7, 2010

Am I right when I am sure? Data consistency influences the relationship between diagnostic accuracy and certainty.

April 2, 2014

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

January 20, 2021

Medical emergency team calls: the need to communicate a resuscitation plan.

January 17, 2007

Managing competing organizational priorities in clinical handover across organizational boundaries.

January 21, 2015

Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics.

November 30, 2016

The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care.

October 28, 2015

The high-reliability pediatric intensive care unit.

May 22, 2013

Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation.

June 28, 2017

Human factors engineering in patient safety.

February 19, 2014

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.

June 28, 2023

Aligning patient safety and stewardship: a harm reduction strategy for children.

December 22, 2021

Patterns of error in interpretive pathology.

August 17, 2022

Safety of office-based lens surgery: U.S. multicenter study

October 25, 2023

Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.

June 24, 2020

Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.

December 14, 2005

Sleep deprivation and clinical performance.

February 22, 2006

Increasing vigilance on the medical/surgical floor to improve patient safety.

February 21, 2007

Diagnostic reliability in teledermatology: a systematic review and a meta-analysis.

August 30, 2023

Role of clinical context in residents' physical examination diagnostic accuracy.

April 13, 2011

Fostering transparency in outcomes, quality, safety, and costs.

October 12, 2016

Time for transparent standards in quality reporting by health care organizations.

August 16, 2017

Identifying patients with sepsis on the hospital wards.

June 7, 2017

Deaths among opioid users: impact of potential inappropriate prescribing practices.

May 15, 2019

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

September 1, 2021

Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals.

June 29, 2022

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

May 14, 2014

The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely collected administrative data.

May 27, 2015

Checklists improve experts' diagnostic decisions.

April 17, 2013

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists.

April 17, 2013

Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?

May 22, 2013

Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors.

January 31, 2018

Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review.

March 29, 2017

Twelve tips on engaging learners in checking health care decisions.

December 11, 2013

Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system.

October 28, 2020

Developing a measure of value in health care.

June 1, 2016

Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.

May 25, 2022

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study.

February 28, 2024

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

October 25, 2023

Systematic review of the impact of physician work schedules on patient safety with meta-analyses of mortality risk.

August 16, 2023

Experiential learning through local implementation of a national chief resident in quality and patient safety curriculum.

September 1, 2019

Am I safe here? Improving patients' perceptions of safety in hospitals.

January 25, 2006

Underdiagnosis of hypertension in children and adolescents.

September 5, 2007

Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.

March 6, 2005

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

June 15, 2016

Types and patterns of safety concerns in home care: client and family caregiver perspectives.

March 9, 2016

Improving radiology report quality by rapidly notifying radiologist of report errors.

October 14, 2015

Encouraging patients to ask questions: how to overcome "white-coat silence."

July 10, 2013

The tension between promoting mobility and preventing falls in the hospital.

May 10, 2017

Saving without compromising: teaching trainees to safely provide high value care.

April 17, 2019

Mandatory presuit mediation: 5-year results of a medical malpractice resolution program.

May 7, 2014

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

November 2, 2022

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

August 19, 2020

Using safety culture results to guide the merger of four general practices in the UK.

May 6, 2020

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Evaluation of an electronic dosing calculator to reduce pediatric medication errors.

February 20, 2019

Transfusion safety: the nature and outcomes of errors in patient registration.

February 20, 2019

Retrieval of iatrogenic intravascular foreign bodies.

December 5, 2012

Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter.

August 22, 2012

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

January 25, 2023

Relationship between nurse burnout, patient and organizational outcomes: systematic review.

August 18, 2021

Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in Pennsylvania.

July 8, 2020

Postoperative video debriefing reduces technical errors in laparoscopic surgery.

July 4, 2007

Impact of a relocation to a new critical care building on pediatric safety events.

April 3, 2024

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

Inaccuracies in assignment of clinical stage for localized prostate cancer.

March 30, 2011

The benefits of health information technology: a review of the recent literature shows predominantly positive results.

March 23, 2011

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

January 13, 2016

An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety.

November 29, 2017

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

March 13, 2013

Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam.

February 20, 2013

Types and patterns of safety concerns in home care: staff perspectives.

October 31, 2012

The association between EMS workplace safety culture and safety outcomes.

October 19, 2011

Family-centered multidisciplinary rounds enhance the team approach in pediatrics.

April 15, 2009

Error traps in pediatric patient blood management in the perioperative period.

September 6, 2023

Pediatric trainee perspectives on the decision to disclose medical errors.

March 30, 2022

Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians.

April 23, 2008

Detection and prevention of medication errors using real-time bedside nurse charting.

August 31, 2005

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Perspective

Cybersecurity and How to Maintain Patient Safety

March 27, 2024

Interview

In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity

March 27, 2024

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

June 28, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Racism and electronic health records (EHRs): perspectives for research and practice.

April 12, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Effect of patient safety education interventions on patient safety culture of health care professionals: systematic review and meta-analysis.

March 29, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

Patient safety issues from information overload in electronic medical records.

September 14, 2022

Medication Safety Certificate Program.

August 24, 2022

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Experiences of transgender people reviewing their electronic health records, a qualitative study.

June 29, 2022

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

WebM&M Cases

The Impact of Communication on Medication Errors

March 15, 2021

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

Patient Safety

September 17, 2020

Global drug shortages due to COVID-19: impact on patient care and mitigation strategies.

July 8, 2020

WebM&M Cases

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

June 24, 2020

WebM&M Cases

A Mistaken Dose of Naloxone 

December 18, 2019

WebM&M Cases

The Lost Start Date: an Unknown Risk of E-prescribing

October 30, 2019

Patient Safety Primers

Patient Safety 101

September 7, 2019

Automated detection of wrong-drug prescribing errors.

August 28, 2019

How to prevent or reduce prescribing errors: an evidence brief for policy authors.

August 7, 2019

Perspective

Medical Scribes and Patient Safety

August 1, 2019

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

July 10, 2019

See More About The Topic

Hospitals

Pharmacists

Facility and Group Administrators

Information Professionals

Policy Makers

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site