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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.

Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10(4):e001593.
Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.
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.
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.
Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17(5):e448-e454.
Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.
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.
Thomas J, Dahm MR, Li J, et al. Health Expect. 2021;24(2):222-233.
Missed or failure to follow up on test results threatens patient safety. This qualitative study used volunteers to explore consumer perspectives related to test result management. Participants identified several challenges that patients experience with test-results management, including systems-level factors related to the emergency department and patient-level factors impacting understanding of test results.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33(2):mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;34(6):580-586.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication. The program reduced overall medical errors, along with the incidence of several specific types of mistakes, including aspiration pneumonia (caused by entrance of foreign materials into the bronchial tree) and errors during management of shock.

Dell-Kuster S, Gomes NV, Gawria L, et al. BMJ. 2020;370:m2917.
This cohort study enrolled 18 sites across 12 countries to assess the validity of a newly developed classification system (ClassIntra v1.0) for assessing intraoperative adverse events. Results indicate that the tool has high criterion validity and can be incorporated into routine practice in perioperative surgical safety checklists or used as a monitoring/reporting tool.
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27(8):1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  
Nguyen AD, Lam A, Banakh I, et al. J Pharm Pract. 2020;33(3):299-305.
This study evaluated the impact of the PeRiopErative and Prescribing (PREP) pharmacist, who is responsible for obtaining the best possible medication history and preparing discharge prescriptions. Results indicate that the inclusion of the PREP pharmacist on the multidisciplinary surgical team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for high-risk patients.
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32(3):184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.
Long E, Barrett MJ, Peters C, et al. Pediatric Anesthesia. 2020;30.
Intubation occurring outside the operating room (OR) is rare but associated with life-threatening adverse events. This review provides an overview of situational, physiological and anatomical contributors to intubation of children outside of ORs; situational challenges – such as human factors or unfamiliar equipment – are most common. Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed, such as systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, multi‐disciplinary team engagement and training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance.
Safer Care Victoria and Victorian Agency for Health Information. Better Safer Care Victoria. https://www.bettersafercare.vic.gov.au/
Large scale tracking of adverse care incidents offers evidence that governments and organizations can use to target care process improvement efforts. This Website houses content from a partnership of two Australian organizations to collect, analyze submitted incident data to work directly with constituents to improve quality and safety across the system.
Nowotny BM, Davies-Tuck M, Scott B, et al. BMJ Qual Saf. 2021;30(3):186-194.
After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.
Leamy K, Thompson J, Mitra B. Australas Emerg Care. 2019;22:221-226.
This article reports the results of a prospective pre-post interventional study undertaken to determine whether providing a simplified information card to patients (in addition to discharge summaries) upon discharge from Australian emergency departments would improve patient awareness of their diagnosis and follow-up requirements. Brief interviews conducted with 112 pre-intervention study participants and 117 who received the short discharge card, indicated statistically significant improvement (73.2% to 89.7%, p<0.001) in patient awareness with the short discharge card. 
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. BMC Med Inform Decis Mak. 2019;19(1):174.
There are challenges to identifying and measuring diagnostic errors in healthcare settings. This systematic review found evidence that team meetings, error documentation, and trigger algorithms in various clinical settings may reduce diagnostic errors. The authors also found that while there have been numerous studies on interventions targeting diagnostic errors, few such interventions are being used in clinical settings.