The PSNet Collection

Medication/Drug Errors

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.

Safety, Equity and Engagement in Maternity Services.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

Honesty and transparency, indispensable to the clinical mission-Parts I-III.

Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55(1).

This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.

Adverse events and their contributors among older adults during skilled nursing stays for rehabilitation: a scoping review.

Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.

Communication regarding adverse neonatal birth events: experiences of parents and clinicians.

Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26(5):200-206.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

Maternal mortality: near-miss events in middle-income countries, a systematic review.

Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99(10):693-707F.

Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.

Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST).

Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.

The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17(7):e615-e621.

Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

September 29, 2021

Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences. To encourage incident reporting among residents, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to capture complications.

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

Arntson E, Dimick JB, Nuliyalu U, et al. Ann Surg. 2021;274(4):e301-e307.

Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals with the highest rates of these conditions through its Hospital-Acquired Condition Reduction Program (HACRP). This study evaluated surgical HACs at three timepoints: before Affordable Care Act (ACA) implementation, after ACA implementation, and after HACRP. While the number of HACs continued to decline after implementation of HACRP, it did not affect 30-day mortality.

A system safety approach to assessing risks in the sepsis treatment process.

Kaya GK. Appl Ergon. 2021;94:103408.

A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Quality and safety in surgery: challenges and opportunities.

Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47(9):604-607.

Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.

This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17(5):e462-e468.

Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.

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