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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.

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.

Irvine, CA: The Patient Safety Movement Foundation; 2021.

Blood transfusion mistakes can result in severe adverse events. This report shares successful strategies to reduce transfusion process errors. The document highlights patient assessment, process standardization, and cross-disciplinary team building as steps toward improving transfusion safety.

Kelen GD, Wolfe R, D’Onofrio G, et al. NEJM Catalyst. Epub 2021 Sep 28.

Emergency department (ED) overcrowding and boarding can result in worse patient outcomes and increased risk of medical errors. This article describes several causes and impacts of ED overcrowding, current solutions, and regulatory and institutional-level actions to reduce ED overcrowding.
Molina RL, Benski A-C, Bobanski L, et al. Implement Sci Commun. 2021;2(1):76.
Checklists are widely used to improve patient safety, including reductions in catheter-related bloodstream infections and surgical morbidity and mortality. This study focuses on implementation of the 2015 World Health Organization Safe Childbirth Checklist (SCC) which aims to prevent maternal and neonatal morbidity and mortality. Twenty-nine participants from fifteen countries with SCC experience completed a survey and twelve were interviewed. Most reported adapting the SCC for their local setting and a wide variety of implementation strategies were used.
Liu LQ, Mehigan S. AORN J. 2021;114(2):159-170.
Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.
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.
Pring ET, Malietzis G, Kendall SWH, et al. Int J Surg. 2021;91:105987.
This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.

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.

ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital. Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using videoconferencing technology. The innovation has successfully reduced patient readmission and SNF length of stay.

Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47(9):556-562.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.
Allison MK, Marshall SA, Stewart G, et al. The Journal of Emergency Medicine. 2021;61(4):396-405.
Transgender and gender nonbinary (trans/NB) people can face discriminatory behaviors when accessing health care services. Trans/NB patients were interviewed about their experiences accessing care in emergency departments. Four themes were uncovered: 1) system and structural issues; 2) interactions with clinicians/staff; 3) perceptions of clinician knowledge and education; and 4) impact on future health and healthcare access. Recommendations for improvement were provided at the system and clinician level.
Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8(2):209-217.
Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential diagnosis.
Worsham CM, Woo J, Jena AB, et al. Health Aff (Millwood). 2021;40(6):970-978.
Adolescent patients transitioning from pediatric to adult medicine may experience patient safety risks. Using a large commercial insurance claims database, the authors compared opioid prescribing patterns and risk for opioid-related adverse events (overdose, opioid use disorder, or long-term use) among adolescents transitioning from “child” to “adult” at 18 years of age. The authors estimate a 14% increased risk for an opioid-related adverse outcome within one year when “adults” just over age 18 years were prescribed opioids that would not have been prescribed if they were under 18 years and considered “children.” The authors discuss how systematic differences in how pediatric and adult patients may be treated can lead to differences in opioid prescribing.

ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.

Concentrated potassium chloride is a high-alert medication for which dosing errors are particularly injurious. This article shares the root causes of IV-push missteps with this medication during a code. Recommendations for improvement shared center on team characteristics and communication.

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.

Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.
Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.