The PSNet Collection

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Curated Libraries

Medication/Drug Errors

Curated Libraries

Maternal Safety

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

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ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.

Tubing misconnections have been associated with medication administration errors, and yet, design strategies to minimize these mistakes are only beginning to be uniformly implemented. This article shares the story of a contrast media administration error associated with communication and handoff errors. The piece recommends focusing on universal design standards to improve administration along with clinical steps to mitigate the potential for this type of error.

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

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ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

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ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.

Packaging and labeling problems hinder safe medication use. This article discusses label appearance and information design as distinct factors that affect the safe use of premixed large volume intravenous solutions.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).

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ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

Education is “predictably disappointing” and should never be relied upon alone to improve safety.

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ISMP Medication Safety Alert! Acute care edition. June 4, 2020;25(11).

Interventions to improve safety must include a range of tactics to ensure success. This article discusses how educational efforts alone will not reliably result in lasting change, human-centered weaknesses inherent in educational approaches and shares a model of overlapping actions required to generate sustainable system improvement.

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

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ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10).

Smart infusion pumps are widely used in hospitals to reduce medication errors but have the potential to create problems if not correctly used. This article discusses heparin administration programming errors and recommends independent double-checks, electronic health record and smart pump interoperability and weight-based dosing as tactics to minimize mistakes.

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

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ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

Dose error-reduction systems (DERS) are standard functions in smart pumps. While they are designed to recognize dosing and programming errors, it has been observed that DERS are not fully utilized in operating rooms (OR). This article shares recommendations for addressing this medication safety gap including working with anesthesia providers and OR team members to establish use of DERS as an expected practice.

Advancing safety with closed-loop communication of test results.

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Quick Safety. December 17, 2019;(52):1-3.

Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares recommendations to enhance handoffs and information sharing amongst care teams and with patients.

NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes.

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Human factors expertise in targeted personnel is a noted health care system improvement strategy. This news piece highlights the National Health Service (NHS) effort to require organizations to develop and employ patient safety specialists with distinct human factors and safety science skill sets to embed system improvements in their organizations and throughout the NHS.

Mental mayhem: the peril of multitasking in medicine.

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Joseph R; Harry E.

Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.

FDA to end program that hid millions of reports on faulty medical devices.

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Jewett C. Kaiser Health News. May 3, 2019.

Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.

How one health system overcame resistance to a surgical checklist.

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Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.

This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.

Air pressure: human factors are the key to a safer flight environment.

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Erich J.

Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.

When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

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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.

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

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ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.

Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.

Pro/con debate: color-coded medication labels.

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Janik LS; Vender JS; Grissinger M; Litman RS.

This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.

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