The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Rappaport DI, Collins B, Koster A, et al. Pediatrics. 2011;128:e1600-7.
Medication reconciliation was initially established as a National Patient Safety Goal (NPSG) in 2005. However, difficulty establishing and implementing effective medication reconciliation approaches led to The Joint Commission suspending evaluation of this NPSG in 2009 and eventually eliminating it as a separate NPSG in 2011. This report from a large health care system provides a detailed template for integrating medication reconciliation into clinician workflow in the outpatient setting. Through a combination of leadership engagement, rapid cycle quality improvement projects, and financial incentives, the organization achieved consistent and sustained improvement in documentation of medication reconciliation for pediatric patients over a 5-year period. As medication reconciliation has been less studied in the ambulatory care setting, this study provides a useful window into the barriers inherent in changing outpatient clinician workflow and the steps this organization took to minimize unintended consequences of the intervention.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.