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ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.
Mahomedradja RF, van den Beukel TO, van den Bos M, et al. BMC Emerg Med. 2022;22:35.
The potential for medication errors may increase due to redeployment and reorganization of hospital resources during COVID-19 surges. In this study of patients hospitalized during the first wave of the pandemic, over 90% had at least one prescribing error three months after hospitalization. Intensive care unit admission and a history of chronic obstructive pulmonary disease (COPD) or asthma were risk factors for prescribing errors. Acknowledging and understanding these risk factors allows hospital leadership to target interventions for this population.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;Epub Jan 28.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.

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.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021. 

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

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.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Osborne V. Curr Opin Psychiatry. 2021;34:357-362.
The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.

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.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Sterling RS, Berry SA, Herzke CA, et al. Am J Med Qual. 2021;36:57-59.
The COVID-19 pandemic has necessitated rapid adjustments in hospital operations to address patient care demands. This commentary discusses how one hospital system utilized their quality and safety staff during the pandemic, and how that experience informed the responsiveness of system-wide quality improvement operations.
Elbeddini A, Almasalkhi S, Prabaharan T, et al. J Pharm Policy Pract. 2021;14:10.
Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.
Blake JWC, Giuliano KK. AACN Adv Crit Care. 2020;31:357-363.
The COVID-19 pandemic has led to many changes in health care delivery. This article discusses one common process change – moving medical devices (such as intravenous (IV) infusion pumps) away from the bedside – and how to support nursing clinical decision-making during IV infusion therapy.  

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5. 
 

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education. 
Ebm C, Carfagna F, Edwards S, et al. J Crit Care. 2020;62:138-144.
Prescribing medications for indications that are not approved by the Food and Drug Administration (FDA) is common but poses a risk for medication errors. The authors of this study used simulation modeling to explore the influence of physician personal preference on off-label medication use during the COVID-19 pandemic.  

March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.
Kanaan AO, Sullivan KM, Seed SM, et al. Pharmacy (Basel). 2020;8:225.
The COVID-19 pandemic has affected the ability of pharmacists to ensure medication safety. This article uses case scenarios to highlight challenges encountered due to the COVID-19 pandemic that required changes in pharmacist roles. Strategies to overcome challenges related to monitoring medications used to treat patients with COVID-19, preventing errors with laboratory reporting, and managing drug shortages are discussed.
Han SM, Greenfield G, Majeed A, et al. J Med Internet Res. 2020;22:e23482.
Social distancing precautions due to the COVID-19 pandemic have led to increased use of telehealth. The authors of this systematic review conclude that there is insufficient evidence to determine whether remote prescribing in primary care changes antibiotic prescribing practices. Future research should further assess remote prescribing to ensure there are no negative impacts on antimicrobial stewardship.