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PSNet: Patient Safety Network
Journal Article

Self-reported uptake of recommendations after dissemination of medication incident alerts.

Cheung K-C, Wensing M, Bouvy ML, et al. BMJ quality & safety. 2012;21:1009-18.

Many organizations issue alerts to warn clinicians and safety professionals about emerging safety issues. The Joint Commission's Sentinel Event Alerts and the Institute for Safe Medication Practices' Medication Safety Alerts are two prominent examples. The effectiveness of these alerts was examined in this Dutch study, which evaluated the degree to which hospital pharmacies implemented three specific medication safety recommendations made by the national Central Medication Incidents Registration (CMR) system. Many pharmacies had yet to implement any of the recommendations 2 years after they were issued, and only one of those recommendations had been implemented by a majority of pharmacies. The authors conclude that passive dissemination of medication safety information is likely an insufficient method.