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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.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Lifflander AL. JAMA. 2019;321:837-838.
Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.
Yin S, Parker RM, Sanders LM, et al. Pediatrics. 2017;140(1):e20163237.
Inaccurate dosing of liquid medications for pediatric patients is known to contribute to medication errors. In this randomized controlled trial, parents of children younger than 9 were able to demonstrate a correct liquid medication dose when they received a dosing tool, such as a syringe, that corresponded more closely to the prescribed medication volume. Directions that include a picture were more likely to lead to accurate dosing compared to text-only instructions. This study adds to prior research demonstrating the need for literacy-friendly medication instructions, especially for dosing of liquid medications to children. Two of the coauthors, Michael S. Wolf and Stacy C. Bailey, described the implications of limited health literacy on patient safety in a past PSNet perspective.
Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
Canadian Patient Safety Institute; CPSI.
Explaining the importance of hand hygiene in the health care setting, this publication provides strategies for patients and families to prevent spreading health care–associated infections.