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Special or Theme Issue
Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15:811-906.
Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
Journal Article > Study
Responding to health information technology reported safety events: insights from patient safety event reports.
Adams KT, Kim TC, Fong A, Howe JL, Kellogg KM, Ratwani RM. J Patient Saf Risk Manag. 2019;24:118–124.
Incident reporting can shed light on safety concerns. In this study, investigators queried a database that receives reports from 575 facilities to identify reports related to health information technology (IT). They examined reports to determine whether the events were resolved at all, and whether the resolution included policy or health IT redesign approaches. Nearly two-thirds of events remained unresolved. Of those that were resolved, the most common approach was additional education or training. The authors conclude that risks associated with health IT persist and further research is needed to understand how these events are resolved. A past PSNet perspective discussed health IT usability design, including both progress and remaining challenges in the field.
Journal Article > Commentary
Beet C, Benoit D, Bion J. Intensive Care Med. 2019;45:505-507.
This commentary discusses current challenges to safety in critical care, such as underperforming decision support, poor organizational learning, and clinician burnout. The authors envision safety improvements due to innovations in processes like wearable monitoring technology that enables rapid response activation, workflow-embedded reflective learning, and patient–clinician collaboration.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Journal Article > Study
Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.
Van de Vreede M, McGrath A, de Clifford J. Aust Health Rev. 2019;43:276-283.
This retrospective study of voluntary safety reports examined medication errors related to electronic prescribing. Researchers found that errors related to electronic prescriptions accounted for a small proportion of medication errors and were of low severity. They suggest that safety monitoring and feedback continue to be needed for electronic prescribing.
Journal Article > Study
Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.
Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019 Jun 13; [Epub ahead of print].
Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
Journal Article > Study
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.
Orenstein EW, Ferro DF, Bonafide CP, Landrigan CP, Gillespie S, Muthu N. JAMIA Open. 2019 Aug 7; [Epub ahead of print].
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.