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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.
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.  
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Austin M; Derk J; Armstrong Institute for Patient Safety and Quality; Johns Hopkins Medicine.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Gabler E.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
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.
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.
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.
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.
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.
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.
Span P.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
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.
McGrory K; Bedi N.
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.
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.
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.