Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

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 has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.

… at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and … with barcode scanning.  … Jessurun JG, Hunfeld NGM, Van Rosmalen J, Van Dijk M, Van Den Bemt PMLA. Effect of automated unit dose …

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.

… about two-thirds of medication administrations. They found a significant association between workarounds and medication … of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front …

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.

… … Br J Clin Pharmacol … Medication safety remains a critical patient safety priority. This systematic review …

… the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, … poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a … factors engineering field, was interviewed by AHRQ WebM&M in 2009. …

Administration of medications at the wrong time—most often more than one hour after the scheduled administration—was found to be the most common type of medication administration error at a Dutch hospital.

… 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.

… may be cost-neutral or cost-saving . … Leenderste AJ,   Van Den Bemt PM, Poolman JB, et al. Preventable hospital admissions …

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.

… 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.