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.
Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765
ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.
Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.
Huff C. Kaiser Health News. November 12, 2021.
Irvine, CA: The Patient Safety Movement Foundation; 2021.
Institute for Safe Medication Practices. December 7, 2021. 1:00-2:30 PM (eastern).
A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.
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.