Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.

The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.

Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.

Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.

… decision-making during IV infusion therapy.   … Blake JWC, Giuliano KK. Flow accuracy of IV smart pumps outside of …

Smart infusion pumps have the potential to improve medication safety, but research suggests that errors remain common and that careful consideration must be given to both design and implementation of such technology. Researchers conducted a survey of five health systems in Indiana to better understand smart infusion pump users' views and knowledge regarding the drug library update process. They identified significant knowledge gaps, especially around the steps necessary to update the drug library.

This retrospective study of smart infusion pump use across multiple hospitals found that the majority of pump alerts are overridden by clinicians, regardless of the type of pump or whether the medication is a high-alert medication. These results suggest a need to augment alerting algorithms to prevent alert fatigue and improve safety.

Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.

Although smart pumps can reduce medication errors, user overrides and workarounds prevent safety features from operating as intended. Researchers used informatics data from 7 hospital systems including a total of 44 hospitals for a 1-year period to determine compliance with built-in dose-error reduction systems and drug libraries. They found differences in compliance both within and across systems. They also found a positive association between pump compliance and type of pump used as well as a positive association between the number of drug library profiles and pump compliance.

Usability weaknesses can contribute to intravenous medication administration errors. This review explores problems in the design and use of intravenous smart pumps that challenge safe use. The author recommends employing innovation with an emphasis on human factors engineering to improve smart pump safety and usability.

… of the American Society of Health-System Pharmacists … Am J Health Syst Pharm … Standardizing drug concentrations …

This commentary describes how surveillance can prevent adverse events and medical errors in critical care.