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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.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.
Canadian Patient Safety Institute;
Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.

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. 
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.  
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
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.
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.
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.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Canadian Patient Safety Institute; CPSI; Health Standards Organization; HSO.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. 
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.