Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 497

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.

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.
McGaughey J, Fergusson DA, Van Bogaert P, et al. Cochrane Database Syst Rev. 2021;2021(11).
Rapid response systems (RRS) and early warning systems (EWS) are designed to detect patient deterioration and prevent cardiac arrest, transfer to the intensive care unit, or death. This review updates the authors’ review published in 2007. Eleven studies representing patients in 282 hospitals were reviewed to determine the effect of RRS or EWS on patient outcomes.
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.
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.
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.
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.

Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16(9):e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82(8):1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39(4):703-717.
Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.
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.
Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.
Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.
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.
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2(3):e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.
Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.