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Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.
Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.
Strube‐Lahmann S, Müller‐Werdan U, Klingelhöfer‐Noe J, et al. Pharmacol Res Perspect. 2022;10:e00953.
Patients receiving home care services are vulnerable to medication errors. Based on survey feedback from 485 home care nurses in Germany, this study found that regular medication training and use of quality assurance principles (i.e., double checking) can decrease the incidence of medication errors in home care settings.
Savva G, Papastavrou E, Charalambous A, et al. Sr Care Pharm. 2022;37:200-209.
Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.

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.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

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.
Coates MC, Granche J, Sefcik JS, et al. Res Gerontol Nurs. 2022;15:69-75.
Older adults, especially those taking multiple medications, are at increased risk for medication self-administration (MSE) errors. Data from the National Health and Aging Trends Study (NHATS) was analyzed to ascertain if the source of the medication ­– picking up from local pharmacy, receiving the medication via mail-order pharmacy, or both ­– impacted MSE or hospitalization. Respondents receiving medications via both mail-order and pick up were more likely to report hospitalizations and medication mistakes.
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. A March 18, 2022 webinar will highlight factors contributing to medication errors in the home and outline strategies to reduce their impact.
Dennison S, Freeman M, Giannotti N, et al. Nurse Educ. 2022;Epub Feb 2.
Reporting medication errors and near misses should be taught to prelicensure nursing students but is not always included in nursing programs. This quality improvement project focused on the near-miss medication error reporting by student nurses. The authors found that dosing errors were 81% of the incidents, but there were multiple contributing factors including communication, competency and education, environmental and human limitations, and policies and procedures. The findings can be helpful to other nursing programs to refocus education on medication errors to areas were students have problems.
Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55:1333-1340.
Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.

ISMP Medication Safety Alert! Acute care edition. February 10, 2022:27(3):1-6.

Best practices evolve over time, given experience and evidence associated with their use. This article summarizes 3 new areas of focus included in current recommendations for sustaining medication safety. The new practices focus on improving the safety of oxytocin use, enhancing vaccine administration through bar coding, and implementing multifocal efforts to reduce high-alert medication errors. A survey accompanies the article to gather data on the presence of the new recommendations in the field. 
Lawson SA, Hornung LN, Lawrence M, et al. Pediatrics. 2022;149:e2020004937.
Insulin is a high-risk medication and can contribute to adverse events in pediatric patients. This paper describes one children’s hospital’s experience implementing a new standardized medication administration process for insulin and the impact on insulin-related adverse drug events (ADEs). Findings indicate that implementation of a PRN (i.e., “as needed”) ordering process and clinician education decreased insulin-related ADEs and reduced the time between blood glucose checks and insulin administration.

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.

RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.
Horsham, PA: Institute for Safe Medication Practices; 2022.
This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371. 

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.