The PSNet Collection

US emergency department visits attributed to medication harms, 2017-2019.

Budnitz DS, Shehab N, Lovegrove MC, et al. JAMA. 2021;326(13):1299.

Previous studies have utilized data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project (NEISS) to analyze harms from medication use. This study uses updated NEISS data to also describe harms from nontherapeutic medication use. Visits to emergency departments for medication adverse events varied by age group, medication class, and intent of use.

Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.

Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20(1):153.

Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.

Association of hospital public quality reporting with electronic health record medication safety performance.

Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4(9):e2125173.

Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.

Canadian Patient Safety Week.

Healthcare Excellence Canada

This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2021 observance, focusing on the importance of essential care partners, will be held October 25th through 29th.

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.

Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.

Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.

ASHP guidelines on the safe use of automated dispensing devices.

Cello R, Conley M, Cooley TW, et al. Am J Health Syst Pharm. 2021;Epub 2021 Aug 29.

This document shares goals and objectives to enhance use of automated dispensing devices for pharmacists, other practitioners, and information system professionals.

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17(5):341-351.

Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. December 2-3, 2021.

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents

July 28, 2021

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6(4):e425.

Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).

EMS Patient Safety in the Field

July 28, 2021

This piece discusses EMS patient safety concerns in the field and discusses operational concerns, clinical concerns, and safety of personnel.

In Conversation With... James Augustine, MD

July 28, 2021

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47(10):646-653.

Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.

Accidental exposures to fentanyl patches continue to be deadly to children.

Rockville, MD: US Food and Drug Administration; 2021.

To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.

Implementation strategies in the context of medication reconciliation: a qualitative study.

Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2(1):63.

Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

Toolkit to Improve Antibiotic Use in Long-Term Care.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

Identifying health information technology usability issues contributing to medication errors across medication process stages.

Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;Epub May 20.

It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.

Resident and family engagement in medication management in aged care facilities: a systematic review.

Manias E, Bucknall T, Hutchinson AM, et al. Expert Opin Drug Saf. 2021:1-19.

Medication errors are a common cause of preventable harm in long-term care facilities. This systematic review explored how residents and families engage in medication management in aged care facilities. Factors hindering effective engagement included insufficient communication between residents, families, and providers; families’ hesitation about decision making; and lack of provider training.

Implementation of patient safety structures and processes in the patient-centered medical home.

Oberlander T, Scholle SH, Marsteller JA, et al. J Healthc Qual. 2021;Epub Jun 13.

The goal of the patient centered medical home (PCMH) model is to reorganize primary care to provide team-based, coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety concerns (e.g., medication safety, diagnostic error, treatment delays, communication or coordination errors) in the context of the PCMH model and explore variability in the implementation of patient safety practices.

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