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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.

Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 27, 2023.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21(1):553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2021:001872082199618.
Safe diagnosis is a complex challenge requiring multidisciplinary approaches. The authors of this article apply high-reliability organization principles to the National Academy of Medicine (NAM) diagnostic process. The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams and organizations can use to optimize the diagnostic process and improve patient outcomes.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14(3):65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  
Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131(1):e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38(6):1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Capolongo S, Gola M, Brambilla A, et al. Acta Biomed. 2020;91(9-s):50-60. 
Based on qualitative data gathered through hospital observations, public health webinars, and expert working groups, the authors propose ten strategies for creating critical care surge capacity and designing resilient hospital facilities to prevent and contain COVID-19 infections. Strategies include strategic site location, functional programs, heating, ventilation, air conditioning, indoor air quality, and digital innovation.
Park S-H, Stockbridge EL, Miller TL, et al. PLoS One. 2020;15:e0235754.
This study merged inpatient discharge data with annual survey data from the American Hospital Association and found that private patient rooms were significantly associated with fewer hospital-acquired MRSA infections; however the effect of private rooms is disproportionate across hospitals. Hospitals with fewer private rooms stand to see the greatest decrease in MRSA infections from adding additional private rooms. These findings can assist hospital administrators making decisions about facility design and renovation.
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17(8):e1669-e1680.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Dennerlein JT, Burke L, Sabbath EL, et al. Hum Factors. 2020;62(5):689–696.
The authors reviewed emerging workplace recommendations for reducing workers’ exposures to COVID-19 and, using human factors and ergonomic principles, proposed an approach for supporting worker safety, health and well-being during the pandemic. The recommended approach includes six key characteristics: (1) leadership commitment; (2) policies, programs and practices fostering supportive working conditions; (3) stakeholder participation at every level of the organization; (4) comprehensive and collaborative strategies; (5) adherence to state and federal regulations, as well as ethical norms, and; (6) commitment to data-driven change and continuous improvement. 
Habli I, Lawton T, Porter Z. Bull World Health Organ. 2020;98(4):251-256.
Using clinical artificial intelligence as an example, these authors posit that digital tools are challenging standard clinical practices around assigning blame and assuring patient safety. They discuss moral accountability for harm to patients and safety assurances to protect patients against such harm, and examine these issues from both a clinician and patient perspective.
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32(3):184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.