Simulated hospital rooms have been used in medical education to identify potential safety threats. In this study, pharmacy students participated in a team-based simulation to identify potential latent errors and then completed a system thinking survey. Survey results indicated students had a good understanding of systems thinking, but only identified about half of the potential errors in the simulated room.

Hospitals, pharmacies, and organizations have developed numerous strategies to prevent look-alike/sound-alike medication mix-ups, but these errors continue to occur. This article suggests a human factors approach by changing the shape of the container for each medication class-type, thus reducing clinicians’ cognitive load. Importantly, drug manufacturers would need to agree on container shapes to prevent confusion when drugs are ordered from different suppliers.

Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.

Cognitive biases can impede diagnostic decision-making and contribute to diagnostic delays and patient harm. This study explored the types of cognitive biases contributing to diagnostic errors in emergency rooms in Japan. The most common biases reported were overconfidence, confirmation bias, availability bias, and anchoring bias. Findings indicate that most diagnostic errors involved overlooking another disease in the same organ group or related organ (e.g., diagnosing headache rather than stroke).

Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.

Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.

Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.

Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.

This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.  

This study evaluated the impact of clinical pharmacist-led interventions on medication errors and preventable adverse drug events among patients in the ICU. The clinical pharmacist performed medication chart review, patient monitoring, and attended medical rounds in order to evaluate the appropriateness of the pharmacological treatment, identify and report drug-related issues, and provide evidence-based recommendations for the management of medication errors. When the pharmacist’s recommendations were implemented by prescribing physicians, approximately half of medication errors were intercepted before reaching the patient, resulting in fewer preventable adverse drug events.

This article discusses global drug shortages due to the COVID-19 pandemic, the impact on patient outcomes and the role of pharmacists and policymakers in mitigating emerging drug shortages related to the pandemic. 

This article describes the implementation of a hospital-wide patient safety strategy aimed at reducing hospital-wide adverse events at a single large hospital in Singapore. The strategy included establishing interdisciplinary patient safety teams to identify areas of preventable harm, determine root causes, improve departmental accountability, and leveraging simulation training. Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining interventions, or death.

This article describes innovative strategies pharmacists in China have explored to address the COVID-19 pandemic, such as establishing prescribing and workforce guidelines, utilizing remote inpatient order review and dispensing, and other telepharmacy approaches.  

Effective communication between patients and physicians is essential to ensuring treatment adherence and improved patient outcomes. This cross-sectional study measured agreement in treatment plan understanding between oncology patients and providers in Saudi Arabia and found that most patients (86.2%) had a suboptimal understanding of their chemotherapy treatment plan. Patients commonly did not understand the planned duration of their treatment or the important toxic effects of chemotherapy.

This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.

This single site study examined the effect of a smartphone messenger app on nursing students’ learning about preventing medication errors in pediatric patients. Researchers concluded that such a tool can reduce medication errors and increase learning among nursing students.

Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.

In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.

Alerts designed to prevent inappropriate prescribing of medications are frequently overridden and contribute to alert fatigue. This study describes the use of machine learning to improve the clinical relevance of medication error alerts in the inpatient setting.