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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.

Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43(6):1693-1704.
While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.
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.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11(11):CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.
Kotwal S, Fanai M, Fu W, et al. Diagnosis (Berl). 2021;8(4):489-496.
Previous studies have used virtual patient cases to help trainees and practicing physicians improve diagnostic accuracy. Using virtual patients, this study found that brief lectures combined with 9 hours of supervised deliberate practice improved the ability of medical interns to correctly diagnose dizziness.
Attia E, Fuentes A, Vassallo M, et al. Am J Health Syst Pharm. 2021;Epub Nov 2.
Anti-coagulants are classified as high-risk medications due to their potential to cause serious patient harm if not administered correctly. This hospital created a multidisciplinary anticoagulant safety taskforce to reduce errors and improve patient safety. The article describes the implementation process, including the use of the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy tool.
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21(7):618.
Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.
McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
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.
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18(17):9206.
Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21(1):1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

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.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2021;Epub Aug 23.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.
Hussein M, Pavlova M, Ghalwash M, et al. BMC Health Serv Res. 2021;21(1):1057.
Accreditation programs, such as Magnet Hospital Program and The Joint Commission, are intended to improve hospital patient safety and quality. This review of 76 studies suggests accreditation has a positive impact on safety culture, efficiency and length of stay. Effects on mortality and healthcare-associated infection rates were mixed.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
Griffin JA, Carr K, Bersani K, et al. Diagnosis (Berl). 2021;Epub Aug 23.
Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.