Through focus groups with patients, family caregivers and nurses, this study explored experiences with medication administration and perceived needs for assistance. Patients and caregivers were generally unaware of errors and primarily attributed administration problems to dosage form (eg, lack of confidence in using syringes). Participants identified lack of training or education about proper administration as contributing to administration errors.

… J Clin Pharm Ther … J Clin Pharm Ther … Crushing pills or capsules is sometimes …

Analysis of video recordings of 10 complex surgical procedures identified an average of 3 deviations (delays or patient safety concerns) per procedure, most often due to problems with communication or environmental design.

This study implemented a standardized handoff protocol, which improved information transfer and satisfaction among perioperative providers.

Clinician decision support systems (CDSS) hold great promise as a means of promoting appropriate care, reducing diagnostic errors, and minimizing medication prescribing errors. However, a recent systematic review found that, taken as a whole, decision support systems achieved only small changes in provider behavior. In this study, a custom-designed CDSS that focused on preventing excessive medication dosages was implemented within a computerized provider order entry system, and resulted in a significant reduction in prescribing errors. Clinicians accepted one in four of the CDSS warnings—a seemingly low proportion that is, in fact, much higher than response rates found in many prior studies of drug alert warnings. The system was carefully tailored to be integrated into provider workflow and to provide only patient-specific warnings, factors that likely contributed to its success.

A quality improvement program successfully reduced the incidence of medication administration errors in pediatric inpatients.

… of the American Society of Health-System Pharmacists … Am J Health Syst Pharm … Implementation of a standardized …

The authors developed a classification scheme for errors in medication administration, and used this to prioritize interventions to prevent such errors.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Patients are increasingly knowledgeable …

The researchers assessed specimen labeling errors before and after implementation of three patient safety projects and found that the initiatives reduced labeling errors.

The authors compared the effectiveness of risk management procedures used during intravenous therapy. They suggest development of better procedures at a national or international level.