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.

Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.

Examining how safety culture influences behavior, this commentary describes a study that identified factors likely to affect clinician adoption of peers' professional or safety-related behaviors, including beliefs in the system approach, error disclosure, and risk reduction strategies.

… and factors that contribute to attentiveness. … Grissinger M. 'Inattentional blindness': what captures your …

This commentary describes how patient safety concepts, such as root cause analysis, safety culture, and health care failure mode and effect analysis, can enhance safety in dental care.

… interruptions , noise, and other distractions to prevent medication errors. …

… published case studies on tubing misconnections and expert recommendations for improvement, this review suggests …

This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.

Based on reports received through numerous national organizations, this article provides public policy recommendations for preventing certain tubing misconnections.

This article describes factors contributing to errors in enteral nutrition delivery and offers strategies to prevent medical tubing misconnections.

This study examined data from a voluntary medication error reporting system (Medmarx) to determine the incidence of harmful pediatric medication errors, the classes of medications frequently associated with error, and the types of errors that occurred. Harmful errors were defined as errors that resulted in temporary or permanent harm to the patient or required immediate intervention to avoid harm. Opioid analgesics, antimicrobials, and antidiabetic agents were most commonly associated with harmful medication errors, collectively accounting for 23.5% of the errors reported. The major type of error was administration at an incorrect dose or quantity (especially for opioid analgesics), followed by omission errors. These findings are similar to those of a previous study. The authors review the systems factors contributing to common medication errors and suggest strategies for error prevention.

The authors analyzed 5 years' worth of Medmarx data and found three trends in intravenous drug administration that predisposed patients to harm: product shortages, calculation errors, and tubing interconnectivity.

The author uses a classification model to outline anesthetic safety considerations.