Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.

… J Patient Saf … J Patient Saf … Cognitive task analysis is a human factors engineering method used to evaluate …

Look-alike and sound-alike medications are known to increase the risk of adverse drug events. Using Veterans Affairs administrative data on prescriptions filled for look-alike and sound-alike medications, researchers found that the potential for medication errors was high, but the actual error rate based on chart review was low.

State-based prescription drug monitoring programs are powerful tools for identifying opioid misuse. This qualitative study of Veterans Affairs primary care physicians demonstrated enthusiasm for using prescription drug monitoring programs to enhance existing efforts to curb the opioid epidemic. A WebM&M commentary highlighted the utility of prescription drug monitoring programs in the hospital.

… JAMA Intern Med … AMA Intern Med … Opioid medications are a known safety hazard, and overdoses of opioid medications … to reduce risks associated with opioids . … Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the …

Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.

Clinical decision support alerts can help identify potential drug–drug interactions, but they can also contribute to alert fatigue. This commentary provides recommendations to inform the design of decision support to address drug–drug interactions. The authors suggest that improvement strategies focus on standardizing terminology and visual cues.

Substantial variation was found between Veterans Affairs hospitals in the frequency of prescribing inappropriate medications for elderly patients.

In contrast to most hospitals and clinics, the Veterans Affairs (VA) health care system has had a fully electronic health record with computerized provider order entry for several years. In this survey, VA physicians generally had positive impressions of the system, with nearly 90% feeling the system improved drug safety and nearly half reporting that serious drug interaction warnings were "very useful." However, the accuracy of drug–drug interaction and allergy warnings within this system are partially dependent upon clinicians manually entering medications prescribed by non-VA providers. As more than one quarter of respondents admitted to not always entering this data, this study highlights the importance of medication reconciliation in establishing accurate medication lists in the ambulatory care setting.

This study found that physicians generally noted the potential patient safety benefits of an electronic prescribing system, though adoption was adversely affected by perceptions of poor usability.

… potential drug-drug and drug-disease interactions to build a medication profiling program into their …

The authors identified inappropriate prescribing for geriatric patients and suggest interventions targeted for specific types of medications.