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Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

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Kepner S, Jones RM. Patient Safety. 2022;4:18-33.

Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

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Grimm CA. Washington DC: Office of the Inspector General; May 2022. Report no. OEI-06-18-00400.

In its 2010 report, the Office of the Inspector General (OIG) found 13.5% of hospitalized Medicare patients experience harm in October 2008. This OIG report has updated the proportion of hospitalized Medicare patients who experienced harm and the resulting costs in October of 2018. Researchers found 12% of patients experienced adverse events, and an additional 13% experienced temporary harm. Reviewers determined 43% of harm events could have been prevented and resulted in significant costs to Medicare and patients.

Exploration of prescribing error reporting across primary care: a qualitative study.

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Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.

Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors.

Prevention of adverse drug events in hospitals.

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Zhu J, Weingart SN. UpToDate. Mar 18, 2022.

Unsafe medication systems in hospitals can lead to adverse drug events (ADEs). This review discusses patient care and organizational factors that contribute to ADEs, methods to detect medication errors, and prevention strategies such as medication reconciliation and enhanced pharmacist participation.

Curated Libraries

Medication/Drug Errors

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

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October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.

Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

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Norris B, Soncrant C, Mills PD, et al. Jt Comm J Qual Patient Saf. 2021;47:489-495.

Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies.

Drive to Deprescribe.

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The Society for Post-Acute and Long-Term Care Medicine.

Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning network to share aggregated data, lessons learned, and educational opportunities to reduce medication adverse events through safe deprescribing.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

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Harper A, Kukielka E, Jones RM. Patient Safety. 2021;3:10-22.

Although medication reconciliation is a common strategy to improve medication safety, barriers to implementation and threats to safety persist. Based on events reported to the Pennsylvania Patient Safety Reporting System, the authors characterized serious events related to medication reconciliation. The most common process failures contributing to patient harm occurred during order entry/transcription and resulted most frequently in the wrong dose or dose omission. The authors suggest risk reduction strategies including defined clinician roles for medication reconciliation, listing the indication for prescribed medications, and adding anticonvulsants to processes for medication with high risk for harm.

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

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de Lemos J, Loewen PS, Nagle C, et al. BMJ Open Qual. 2021;10:e001161.

Adverse drug events – many of which are preventable – are a major source of patient harm. This cross-sectional study explored the causes of preventable adverse drug events (ADEs) and how patients, families, and providers can prevent them. The study finds that the most common causes of preventable ADEs involved providers not ensuring that patients and/or family understood the medication plan or could identify symptoms of side effects. The researchers used the study findings to develop learning messages for providers, patients, and families and to implement a preventable ADE surveillance system.

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

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ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing.

Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care.

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Chin DL, Wilson MH, Trask AS, et al. J Med Syst. 2020;44:185.

Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. The researchers describe a novel approach to using existing CDS systems to detect medication prescribing errors based on drug-drug interaction and allergy alert overrides. Dose alert overrides had high sensitivity to detect medication prescribing errors occurring in an inpatient setting.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

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Gibson R, MacLeod N, Donaldson LJ, et al. Addiction. 2020;115:2066-2076.

Methadone and buprenorphine are commonly prescribed to treat opioid use disorder, but their use presents patient safety risks. Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care stemmed from errors in dispensing practices (e.g. wrong patient, incorrect dose, incorrect formulation). Staff- and organization-related factors – such as not following protocols, poor continuity of care – contributed to more than half of the incidents.

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