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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.

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163(1):83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48(1):12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
De Angulo NR, Penwill N, Pathak PR, et al. Hosp Pediatr. 2021;Epub Dec 24.
This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient care during the first months of the COVID-19 pandemic. Participants reported changes in workflows, discharge and transfer process, patient and family engagement, and hospital operations.
Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48(1):61-64.
Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.
Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19(6):521-526.
Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.
Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11(12):e055247.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17(8):e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4(12):e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.
Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.
This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17(8):531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.

Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.