The PSNet Collection

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

Start the year off right by addressing these top 10 medication safety concerns from 2021

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Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.

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Medication/Drug Errors

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction.

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Joseph A. Stat News. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

Disrespectful behavior in healthcare: has it improved? Please take our survey!

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ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

The pain was unbearable. So why did doctors turn her away?

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Szalavitz M. Wired Magazine. August 11, 2021.

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

Geriatric medication reconciliation in the home setting.

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Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

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ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5.

Process change can introduce opportunities for error into established practice. This article builds on results of an earlier survey to expand the record on the types of COVID vaccine errors such as wrong patient age, dilution problems, and vaccine card confusion.

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

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Kaplan A. NBC News. April 21, 2021.

Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.

Black or 'other'? Doctors may be relying on race to make decisions about your health.

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Smith J, Spodak C. CNN. April 25, 2021.

Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.

Endometriosis affects 1 out of 10 women like me. Yet it often takes a decade to get diagnosed.

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Peikoff L. NBC News. March 31, 2021.

Patients with endometriosis often experience care delays and misdiagnoses that contribute to harm. This news story discusses a patient’s experience with common contributors to delay that include Insufficient clinical knowledge of the disease and a lack of uniform treatment guidance.

COVID-19 dominates annual list of patient safety concerns.

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Brooks M. Medscape Medical News. March 15, 2021.

Safe care is influenced by both global and local changes in the environment. This news story summarizes a prioritized list of patient safety concerns--many of which were heightened due to the COVID-19 pandemic. Inequities due to ethnicity, lack of emergency readiness and ineffective pandemic readiness are highlighted.

Keeping patients on track with preventative care during pandemic.

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Quick Safety. March 2021;58:1-2.

The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This article recommends several strategies for gaining patient trust in the system to keep them safe from exposure which include dedicated spaces for preventative services and proactive encouragement on the importance of screenings such as mammograms.

Families are struggling to use medicines at home — we must truly involve them in their own safety.

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Morris S, O’Hara J. Pharmacuetical Journal. February 26, 2021.

It is a challenge to track medical errors that take place in the home environment, yet it is understood they happen and can cause harm. This article discusses errors that parents make in providing medications to their children. The authors advocate for engaging parents as partners to improve care safety in the home.

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