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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.

Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37(4):e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Canadian Patient Safety Institute;
Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.
Young E. The Atlantic. 2020.
Preconceptions of disease can impact the medical and social response to patients with chronic conditions. This article discusses patients with COVID-19 who survive the virus and describes ineffective support due to lack of understanding and empathy regarding the long-term debilitation survivors experience.    
Hado E, Friss Feinberg L. J Aging Soc Policy. 2020;32(4-5):410-415.
These authors discuss the role of family caregivers during the COVID-19 pandemic and suggest avenues to support the relationship between families and residents of long-term care facilities, including strengthening communicating channels, activating family councils, and utilizing gerontological social work students.
Massachusetts Sepsis Consortium.
Delayed diagnosis of sepsis is a primary patient safety concern. This campaign raises awareness of the symptoms of sepsis to engage patients in timely diagnosis and safe treatment of the condition. 
Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. A PSNet Human Factors Primer on human factors expands on these concepts.  
Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
King L, Peacock G, Crotty M, et al. Health Expect. 2019;22:385-395.
Patients and families have the potential to help medical teams proactively detect clinical deteriorations. This qualitative study with consumer advocates resulted in a comprehensive model for empowering patients to accurately activate rapid response systems.
Sutton E, Brewster L, Tarrant C. Health Expect. 2019;22:650-656.
Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Canadian Patient Safety Institute; CPSI; Health Standards Organization; HSO.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. 
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of family-centered rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Graham J.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Hemmelgarn C. Health Aff (Millwood). 2018;37:1332-1334.
Lack of transparency regarding errors in patient care contributes to harm, mistrust, and inclination toward legal action. This commentary offers insights from a parent whose daughter died from medical error and the resistance she faced when trying to understand what happened. The author encourages health care to embrace strategies that improve dialogue and explanation regarding errors including communication-and-resolution programs.
Schenk EC, Bryant RA, Van Son CR, et al. J Nurs Care Qual. 2019;34(1):73-79.
Patients and families enhance safety when invited to express concerns and provide feedback about their care. Qualitative interviews of hospital staff, patients, and families highlighted both patients' and families' unique skills as safety advocates as well as barriers to speaking up. An Annual Perspective delineates tools to promote patient engagement in safety.
Bell SK, Roche SD, Mueller A, et al. BMJ Qual Saf. 2018;27(11):928-936.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. Patients and families are often the first to notice changes in their well-being and consistently identify unique adverse events that are not detected through provider-driven means. This cross-sectional survey asked patients currently hospitalized in an intensive care unit (ICU) and their families about their comfort discussing safety concerns with their health care team, then validated those responses with an Internet-recruited nationwide cohort of patients and families who had been previously cared for in ICUs. Many current ICU patients and families expressed some reticence to speak up. Common reasons cited were concern that the health care team was too busy, fear of being labeled a troublemaker, and worry that the team would judge them for not understanding the medical details of their care.