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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.
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.
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.
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.  
Demiris G, Lin S-Y, Turner AM. Stud Health Technol Inform . 2019;264:1159-1163.
Patient safety in the home has not been well defined and there have been few studies of this setting. This study examines the concept of patient safety in the home and identifies personal health information management tools to support and maximize patient safety in the home. The study findings demonstrate the physical, emotional, social and functional dimensions of patient safety in the home and ways for informatics tools to maximize safety aspects.
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.
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.
Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.
The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.
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.
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.
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.
Jalal H, Buchanich JM, Roberts MS, et al. Science (1979). 2018;361.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
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.
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.
Meyer-Massetti C, Meier CR, Guglielmo J. Int J Clin Pharm. 2018;40:325-334.
The incidence of preventable adverse events in patients receiving home care has been found to be comparable to hospitalized patients. This review sought to characterize medication errors in home care patients and found that the most common type of medication error was the prescribing of potentially inappropriate medications to elderly patients.