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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.

Agarwal M, Lovegrove MC, Geller RJ, et al. J Pediatr. 2020;219.
Parents are advised to keep medications inaccessible to young children to avoid accidental ingestions. This study prospectively enrolled nearly 4,500 individuals calling poison control centers about unsupervised solid dose medication exposure in young children (ages 5 years and younger) to identify the types of containers from which young children accessed these medications. The majority of incidents (71.6%) involved children 2 years and younger. Incidents were equally divided among calls involving prescription-only medications, over-the-counter (OTC) projects requiring child-resistant packaging, and OTC projects not requiring such packaging. One-third of all incidents involved medication that had been removed from the original container; this was more likely in incidents involving prescription drugs compared to OTC drugs (adjusted odds ratio, 3.39; 95% CI, 2.87-4.00).  These findings suggest that unsupervised medication exposures in young children are just as often the result of adults removing medications from original packaging as the result of improper use or failure of child-resistant packaging.

FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. March 24, 2020.

Device related errors reduce the safety of medications. This announcement highlights concerns associated with the use of epinephrine auto-injectors. Recommendations to address the problem include patient review of instructions and practice with the device to ensure its effective use in emergent situations.
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. 
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.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143(4):e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Leonard JB, Klein-Schwartz W. Ame J Health-syst Pharm. 2019;76(5):264-265.
Patient and family medication administration mistakes can result in medication errors at home. This commentary describes the problem of "pill dumping," where patients combine their daily medicines into a spare vial. However, patients are at risk for mistakenly taking a vial of a single medication instead of their pill-dump vial and inadvertently overdosing. The authors suggest medication counseling and use of daily pill boxes as tactics to prevent this type of error.
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.
Medical care overuse is emerging as a patient safety hazard that can result in harms such as unneeded testing and poor end-of-life care. This collection of articles and audiovisual resources explore factors that contribute to medical care overuse and its impact on patients and their families.
Kirby J; Cannon C; Darrah L; Milliman-Richard Y.
Parents are important advocates for the safe care of their children. This commentary describes how one hospital built a toolkit to operationalize family members as partners to improve safety. The organization applied high reliability concepts to identify, recognize, and support projects at the hospital to successfully use patients' perspectives to design improvements.
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.
Society for Healthcare Epidemiology of America; SHEA.
Engaging patients and families in their care can reduce risks. This brochure provides information about hospital-acquired infections and offers several tactics patients and families can adopt to protect themselves and others from infection. Recommendations include ensuring hand hygiene compliance by clinicians and visitors, taking antibiotics as prescribed, and recognizing infection symptoms.
Parand A, Garfield S, Vincent C, et al. PLoS One. 2016;11(12):e0167204.
Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.
Rosenberg RE, Rosenfeld P, Williams E, et al. J Nurs Care Qual. 2016;31(4):318-326.
Engaging patients and families as partners in safety is increasingly recognized as an important strategy in health care. This qualitative study examined parents' perspectives regarding their role in maintaining the safety of their children in the hospital setting. Investigators uncovered components of hospital culture and practice that affect parent engagement and recommend staff training to enhance clinician–parent partnerships.
Langer T, Martinez W, Browning DM, et al. BMJ Qual Saf. 2016;25:615-25.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.
Joint Commission.
Patient engagement is increasingly recognized as a key strategy to enhance safety in health care. This article describes how failure to communicate effectively with patients can reduce safety and outlines tactics to involve patients and families in care transitions.
Chicago, IL: Health Research & Educational Trust; 2015.
Patient and family advisor programs have been implemented in health care as a way to incorporate the experiences of consumers into safety improvement work. This guide provides a framework to help hospitals develop partnership initiatives that focus on advisor recruitment, education, and teamwork to enhance efforts to engage patients and families in this role.