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.

Technology, Education and Safety.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis.

Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2021;Epub Sep 12.

Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43(5):1404-1411.

This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.

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.

The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned,

Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38(12):1281-1288.

Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.

A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality.

Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133(3):698-706.

Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.

Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations

September 29, 2021

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.

The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis

September 29, 2021

Medication administration errors are a common source of patient harm. Developed at Cincinnati Children’s Hospital Medical Center (CCHMC), MED.Safe is an automated software package designed to monitor high-risk intravenous (IV) medications in neonatal intensive care units (NICUs) and identify medication administration discrepancies.

Emergency departments are higher-risk locations for wrong blood in tube errors.

Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61(9):2601-2610.

Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.

Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.

Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18(16):8391.

The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.

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.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28(10):2202-2211.

Based on the SaferDx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.

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.

Prevention of perioperative medication errors.

Nanji K. UpToDate. Aug 11, 2021.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

"My whole room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring system.

Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.

Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.

Wrong-patient orders in obstetrics.

Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138(2):229-235.

Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.

Systematic review of intraoperative anesthesia handoffs and handoff tools.

Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132(6):1563-1575.

Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.

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