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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.

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.  
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.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health 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.
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
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.

Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.

Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.
Roter DL, Wolff J, Wu A, et al. BMJ Qual Saf. 2017;26(6):508-512.
Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.
Donaldson LJ. BMJ Qual Saf. 2015;24(10):603-604.
Narrative elements of care failures can help motivate commitment to patient safety work by placing the incident in context. Exploring the value of patient perspectives associated with adverse events, this commentary suggests that improvement leaders consider the patient experience when designing harm reduction efforts.
Leone D, Lamiani G, Vegni E, et al. Patient Educ Couns. 2015;98:446-52.
In this study, Italian physicians were videotaped in a simulated scenario of error disclosure to a family member. Physicians were much more likely to use the term error, apologize, and display empathy when the scenario represented an instance of clear responsibility rather than shared responsibility or system failure.
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.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.