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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.

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.

Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17(22):8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38(6):1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29(3):174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed.
Horng S, Joseph JW, Calder S, et al. JAMA Netw Open. 2019;2(12):e1916499.
The adoption of electronic health record (EHR) systems has led to unanticipated patient safety concerns, such as duplicate orders for tests and medications. This study found that the implementation of a visual aid within the computerized provider order entry (CPOE) system to flag duplicate orders was associated with a 49% decrease in duplicate laboratory orders and a 40% decrease in radiology orders. The authors did not find a decrease in duplicate medication orders. A previous WebM&M commentary describes an adverse event related to duplicate medication orders.
Melton KR, Timmons K, Walsh KE, et al. BMC Medical Inform Decis Mak. 2019;19(1):213.
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.
Yeh J, Wilson R, Young L, et al. J Nurs Care Qual. 2019.
Prior research has found that nonactionable alarms are common and contribute to alarm fatigue among providers in intensive care units. This single center study employed an interprofessional team-based approach to adjust the default thresholds for arrhythmias and specific parameters such as oxygen saturation, which resulted in a nearly 47% reduction in nonactionable alarms over a two-week period.
Lifflander AL. JAMA. 2019;321:837-838.
Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.
Wong A, Rehr C, Seger DL, et al. Drug Saf. 2019;42:573-579.
Although clinical decision support is intended to improve safety, decision support alerts often result in alert fatigue and overrides. This prospective observational study examined overrides for exceeding the maximum dose of a medication in the intensive care unit. Researchers determined that insulin was the most frequent medication for which a maximum dosage alert was overridden. In almost 90% of cases, the overrides were deemed clinically appropriate. The authors conclude that more intelligent clinical decision support for medication dosing is needed to balance safety with alert fatigue in the intensive care unit. A past PSNet perspective discussed the challenges of implementing effective medication decision support systems.
Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.
This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.
Kizzier-Carnahan V, Artis KA, Mohan V, et al. J Patient Saf. 2019;15:246-250.
This study found that laboratory values designated as "abnormal" or "panic" in the electronic health record, which are considered passive alerts, are very common for patients in the intensive care unit. The authors suggest that these passive alerts contribute to the pervasive problem of alert fatigue in the intensive care unit.
Genco EK, Forster JE, Flaten H, et al. Ann Emerg Med. 2016;67:240-248.e3.
The concept of "number needed to treat" is used to quantify the number of patients who would need to undergo therapy to prevent one adverse clinical outcome. This study of opioid prescribing in an academic emergency department found that prescribers had to view more than 123 unnecessary alerts to prevent one adverse drug event. Studies such as this help quantify the number needed to treat for computerized warnings, a critical step forward in understanding and mitigating alert fatigue.
DiPoto JP, Buckley MS, Kane-Gill SL. Drug Saf. 2015;38:311-7.
A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.
Balasuriya L, Vyles D, Bakerman P, et al. J Patient Saf. 2017;13(3):144-148.
This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue.
Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.
Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.