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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.

Schrade B, Teegardin C. Unprotected: Broken promises in Georgia’s senior care industry. Atlanta Journal-Constitution. Sept-October 2019.
Assisted living facilities have challenges that reduce the quality and safety of care. This news investigation examines how poor management, staffing shortages, and poor caregiver training were unchecked by systemic failures in correcting problems to protect residents. 
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.  
Schulte F; Fry E.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
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.
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.
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.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Mittal V. Pediatr Clin North Am. 2014;61:663-70.
Family-centered rounds are multidisciplinary rounds that involve patients and their families, include the complete case presentation and discussion, and engage them in decision making. This commentary discusses how family-centered rounds can contribute to patient safety, such as better doctor–patient relationships, and barriers to implementing them, including perceptions that rounds would take longer.
Paciotti B, Roberts KE, Tibbetts KM, et al. Jt Comm J Qual Patient Saf. 2014;40(4):187-192.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
Agency for Healthcare Research and Quality; AHRQ; HHS; US Department of Health and Human Services.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.