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Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Canadian Patient Safety Institute;
Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.
Agarwal M, Lovegrove MC, Geller RJ, et al. J Pediatr. 2020;219.
Parents are advised to keep medications inaccessible to young children to avoid accidental ingestions. This study prospectively enrolled nearly 4,500 individuals calling poison control centers about unsupervised solid dose medication exposure in young children (ages 5 years and younger) to identify the types of containers from which young children accessed these medications. The majority of incidents (71.6%) involved children 2 years and younger. Incidents were equally divided among calls involving prescription-only medications, over-the-counter (OTC) projects requiring child-resistant packaging, and OTC projects not requiring such packaging. One-third of all incidents involved medication that had been removed from the original container; this was more likely in incidents involving prescription drugs compared to OTC drugs (adjusted odds ratio, 3.39; 95% CI, 2.87-4.00).  These findings suggest that unsupervised medication exposures in young children are just as often the result of adults removing medications from original packaging as the result of improper use or failure of child-resistant packaging.

FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. March 24, 2020.

Device related errors reduce the safety of medications. This announcement highlights concerns associated with the use of epinephrine auto-injectors. Recommendations to address the problem include patient review of instructions and practice with the device to ensure its effective use in emergent situations.
Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. A PSNet Human Factors Primer on human factors expands on these concepts.  
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
King L, Peacock G, Crotty M, et al. Health Expect. 2019;22:385-395.
Patients and families have the potential to help medical teams proactively detect clinical deteriorations. This qualitative study with consumer advocates resulted in a comprehensive model for empowering patients to accurately activate rapid response systems.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

Gabler E. New York Times. May 31, 2019.

Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Sutton E, Brewster L, Tarrant C. Health Expect. 2019;22:650-656.
Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Canadian Patient Safety Institute; CPSI; Health Standards Organization; HSO.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. 
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.
The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.
Schulte F; Fry E.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.