Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.  

Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.

Medication reconciliation is a common tool used to identify medication discrepancies and inconsistencies. This study explored clinically relevant deviations in a patient’s medication list by comparing the personal heath record (used by patients) and medication reconciliation during hospital admission. Clinically relevant deviations were higher among patients with individual multi-dose packaging and patients using eight or more medications.

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. 

… J Patient Saf … Anticoagulants , such as low-molecular-weight … one-third of LMWH users admitted to one hospital over a five-month period. … Slikkerveer M, van de Plas A, Driessen JHM, et al. Prescribing errors with …

… and reducing potentially preventable readmissions is a patient safety priority . This study found that 16% of … errors, non-adherence, and handoff or transition errors. … Uitvlugt EB, Janssen MJA, Siegert CEH, et al. Medication-related hospital …

This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.

This systematic review examined the effects of medication-related interventions on readmissions, medication errors, adverse drug events, medication adherence, and mortality. Meta-analyses indicate that medication-related interventions reduce 30-day readmissions and the positive effect increased with higher intervention intensities (e.g., additional intervention components). Additional research is required to determine the effects on adherence, mortality, and medication errors and adverse drug events.

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.

… J Am Med Inform Assoc … J Am Med Inform Assoc … Workarounds occur frequently in … about two-thirds of medication administrations. They found a significant association between workarounds and medication …

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.

… 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 . …

This study discovered that medication administration at nursing homes is an error-prone process, particularly around administration techniques and wrong time errors. A past AHRQ WebM&M commentary discussed a case of a nurse who bypassed the safeguards of an automated dispensing system at a nursing facility, which led to a serious medication error.