Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

… J Am Med Dir Assoc … Transitioning from hospital to nursing … should look beyond currently available quality measures. … Field  TS, Fouayzi H, Crawford S, et al. The association of nursing home …

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

The COVID-19 pandemic has affected the ability of pharmacists to ensure medication safety. This article uses case scenarios to highlight challenges encountered due to the COVID-19 pandemic that required changes in pharmacist roles. Strategies to overcome challenges related to monitoring medications used to treat patients with COVID-19, preventing errors with laboratory reporting, and managing drug shortages are discussed.

… N Engl J Med … This study randomized primary care practices across … strategy to prevent serious fall injuries. N Engl J Med . 2020;383(2):129-140. doi: 10.1056/NEJMoa2002183. Epub …

Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

… Journal of general internal medicine … J Gen Intern Med … Electronic health record alerts contribute …

Determining the severity of harm or potential harm is a challenge in patient safety. Investigators asked physicians, nurses, and pharmacists to rate the severity of harm for specific adverse events including falls, health care–associated infections, pressure ulcers, and blood product errors. The authors recommend using two raters to determine harm in order to achieve reliable estimates.

Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.

Dementia appeared to be an independent risk factor for medication errors among a cohort of geriatric nursing home patients who were prescribed the anticoagulant warfarin. Increased nursing staff time seemed to mitigate this risk.

This article comments on the patient safety implications of drug shortages and a proposed approach to guide clinical decision-making when distributing medications during shortages.

This study reports on the initial findings of a novel survey intended to evaluate safety culture in nursing homes, the Survey on Resident Safety in Nursing Homes.

This commentary suggests strategies for improving prescribing safety, including linking pharmacy and laboratory data through health information technology.

Warfarin therapy is commonly associated with adverse events despite specific indicators designed to capture them and guide prevention efforts. This study adopted the SBAR communication tool as part of a protocol to improve the quality of warfarin management in the nursing home setting. Using a facilitated telephone communication between nurses and physicians in 26 nursing homes, the patients randomized to the SBAR approach had statistically significant improvements in their therapeutic levels and a non-statistically significant reduction in adverse events. A past AHRQ WebM&M commentary discusses a case of inadequate warfarin monitoring that resulted in an adverse event for a nursing home patient.

Failure to follow up on test results has been linked to missed and delayed diagnoses in the ambulatory setting. Although electronic health records (EHR) hold great promise for addressing this issue, this systematic review found only modest published evidence linking EHR use to improved laboratory test monitoring. This finding corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests and radiologic studies despite use of an EHR. The authors conclude that further research will be required to develop optimal test management systems within electronic medical records.

This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.

Prior studies have documented suboptimal safety culture in long-term care facilities. This AHRQ-funded study used surveys and interviews to examine one specific aspect of safety culture—communication between nurses and physicians. Nurses noted several problems with communication, including lack of receptiveness by physicians and difficulty reaching physicians. Many nurses noted instances of unprofessional or disruptive behavior by physicians. Nurses acknowledged the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this AHRQ WebM&M commentary.

This study discovered that clinical decision support built within a CPOE system can improve physician prescribing behavior in long-term care settings.

… Journal of general internal medicine … J Gen Intern Med … Patients transferred from hospitals to …