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 …

This cross-sectional study examined how and to what extent non-dispensing pharmacists embedded in a general practice reported solving medication problems through clinical medication reviews in an elderly cohort of patients.  The reviews identified 1,292 drug therapy problems, citing overtreatment most frequently (24%) followed by undertreatment (21%) errors. Integrating non-dispensing pharmacists into general practice may help identify and solve drug therapy problems in the elderly in this setting.

This qualitative study found that postdischarge home visits from pharmacists focused on the details of the medication regimen rather than health beliefs and extent of medication adherence. The authors recommend an increased focus on patient engagement during these home visits.

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 …

… Qual Improv Rep … This commentary describes the results of a Six Sigma improvement project to reduce risks of parenteral …

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

Patients are susceptible to various problems following hospital discharge, including medication errors. This commentary suggests that improving the transfer of patient medication history, performing home visits to follow up with patients, and collaboration between primary care and community pharmacy can help reduce adverse drug events after patients are discharged from the hospital.

… 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. …

Conducted in 70 primary care clinics in the Netherlands, this study found that clinicians' perceptions of safety culture bore little relationship to the actual incidence of patient safety events in their clinics.

… only one of those recommendations had been implemented by a majority of pharmacies. The authors conclude that passive …

This study sought to quantify adverse events associated with physical therapy and occupational therapy in the outpatient setting but was limited by incomplete record keeping.

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.