Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Enhancing alarm management to decrease unnecessary alerts is a critical step in making decision support usable for health care professionals. This intervention study describes how inpatient pharmacists modified alerts on intravenous infusion pumps to reduce the number of clinically irrelevant alerts. A previous AHRQ WebM&M commentary describes consequences of overriding an important alert as a result of alarm fatigue.

This study found that smart pumps protect against many serious medication errors, potentially saving approximately $30 million per year for the Carolinas HealthCare System. This return-on-investment analysis was used to gain support for creating a medication safety officer position.