Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 238

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33(4):mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 
Mulac A, Hagesaether E, Granas AG. J Adv Nurs. 2022;78(1):224-238.
Medication dosing errors can lead to serious patient harm. This retrospective study found that the majority of dose calculation errors reported to the Norwegian Incident Reporting System involved intravenous administration such as intravenous morphine. These errors occurred due to lack of proper safeguards to intercept prescribing errors, stress, and bypassing double checks.

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61(9):2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17(5):e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;30(12):1021-1030.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

Küng K, Aeschbacher K, Rütsche A, et al. Int J Qual Health Care. 2021;33(1).
Barcode medication administration (BCMA) systems are one strategy to reduce medication administration time and preparation errors. This study sought to assess the influence of BCMA on the rate of medication preparation errors and time spent by registered nurses on medication preparation tasks. Use of BCMA decreased wrong medication and wrong dosage errors, and wrong patient, wrong form, and ambiguous dispenser errors did not occur post-intervention. Additionally, BCMA decreased medication preparation time.
Zheng WY, Lichtner V, Van Dort BA, et al. Res Soc Admin Pharm. 2021;17(5):832-841.
This systematic review sought to determine the impact of automated dispensing cabinets (ADCs), barcode medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) used by hospitals in reducing controlled substance medication errors in hospitals. Overall, only 4 studies (out of 16) focused directly on controlled medications. A variety of types of errors (e.g., log-in, data, entry, override) compromised patient safety. High-quality targeted research is urgently needed to evaluate the risks and benefits of medication-related technology.
Owens K, Palmore M, Penoyer D, et al. J Emerg Nurs. 2020;46(6):884-891.
Barcoding of medications is one approach to improving medication administration safety. In this study, direct observation was used to compare medication error rates and nursing satisfaction before and after implementation of bar-code medication administration in a community hospital emergency department. Three months after its implementation, the medication administration error rate significantly decreased by 74.2% and nursing satisfaction increased.  
Joseph R, Lee SW, Anderson SV, et al. Am J Health-System Pharm. 2020;77(15):1231-1236.
This observational study assessed the impact of smart infusion pumps and electronic health record (EHR) interoperability in intensive care settings. Findings indicate that interoperability led to an increase in documentation of rate changes, a decrease in alerts triggered, and increased perceptions of clinical data accuracy and efficiency among pharmacists.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131(4):1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.  
Veen W, Taxis K, Wouters H, et al. J Clin Nurs. 2020;29(13-14):2239-2250.
Using data from four hospitals in the Netherlands that use barcode-assisted medication administration, the authors of this study sought to identify potential risk factors associated with workarounds performed by nurses. Potential risk factors identified include the timing of medication rounds, the route of administration, drug classification, and the nurse-to-patient ratio. Future quality improvement measures could focus on modifiable risk factors including nurse workload and nurse staffing.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.

McCook A. Preventing medication errors at small and rural hospitals.  Pharmacy Practice News. May 6, 2020.

Small and rural facilities experience similar medication safety challenges but can have deficient resources to address them. This article outlines how lack of staff for adequate double-checks and robust barcode technology can enable high-alert medication errors in these environments. Approaches highlighted to improve medication safety are customized alerts and education.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 

ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25.

Errors in IV medication use can result in serious adverse health consequences. This article shares an analysis of approximately 200 oxytocin incident reports. Five areas of concern identified include prescribing, look alike/sound alike packaging, preparation, administration and communication problems. Patient engagement, bar coding use and verbal order reduction are highlighted amongst the listed improvement strategies.