The Rise of Human Factors in Medication Safety Research

摘要

Despite 20 years of interest and calls to improve, 1 , 2 avoidable medication-related harm in health care settings has not appreciably reduced. 3 During this time, many projects have addressed this problem with varying degrees of success. 4 , 5 In this issue of the Journal , Procaccini and colleagues report on one such project, in which a risk assessment of pro re nata (PRN) medication orders in a pediatric ICU (PICU) led to the introduction of an educational intervention and an order set. 6 Although the educational intervention alone produced a statistically significant improvement of awareness of Joint Commission standards among caregivers, it did not in itself result in improved compliance with Joint Commission Medication Management (MM) standards. However, implementation of the order set did. The impact of these interventions on patient outcomes and medication error rates has yet to be evaluated.