Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 

Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.

… and reducing potentially preventable readmissions is a patient safety priority . This study found that 16% of …

Despite their health benefits, anticoagulants place patients at high risk for medication-related harm. Researchers found that anticoagulants were responsible for 8.3% of medication errors documented in a Dutch national database, and that human behavior most commonly caused those errors. A WebM&M commentary elaborates upon the safety challenges of novel oral anticoagulants.

Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.

This commentary describes the results of a Six Sigma improvement project to reduce risks of parenteral medication administration errors that cause harm. Strategies tested included education, drug delivery modifications, and ensuring administration instructions were available.

… British journal of clinical pharmacology … Br J Clin Pharmacol … Medication safety remains a critical patient safety priority. This systematic review …

Numerous studies have identified unintended consequences associated with health information technology (IT) and computerized provider order entry, but most of these focused exclusively on the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, extends prior studies by examining medication errors related to IT in community pharmacies as well as hospitals. Overall, nearly one in six medication errors was attributable to problems with IT. Human factors engineering issues, such as poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a founder of the human factors engineering field, was interviewed by AHRQ WebM&M in 2009.

… only one of those recommendations had been implemented by a majority of pharmacies. The authors conclude that passive …

More than half of hospitalized patients in this Dutch study experienced an adverse drug event, most of which were not preventable and had minimal clinical consequences.

This study noted no significant difference in medication administration errors regardless of whether medication cart filling methods were dictated by medication name or round time.

This case-control study attempted to identify factors that predicted whether patient harm resulted from medication errors.

… algorithms designed to prevent prescribing errors within a computerized provider order entry system. The decision … developed and tested in comparison to errors identified by a trained pharmacist. …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … A decision support system combined with computerized provider …

… … The process of medication reconciliation —reviewing a patient's medication regimen to eliminate unintended … of involving patients in safety efforts, which is a 2009 Joint Commission National Patient Safety Goal . …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … This study discovered that medication … around administration techniques and wrong time errors. A past AHRQ WebM&M commentary discussed a case of a nurse who bypassed the …

… study further elucidates patient factors (e.g., impaired cognition, co-morbidities) associated with …

Although most inpatient adverse drug events are considered preventable, this study found that independent reviewers reached only fair agreement regarding the preventability of individual errors.