This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.

Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.

A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.

… Journal of pain & palliative care pharmacotherapy … J Pain Palliat Care Pharmacother … Opioids are particularly …

Pharmacists are increasingly leading hospital medication reconciliation programs. Pharmacists at one institution resolved as many as 3.5 medication errors per patient, nearly half of these were considered significant or serious. Although the nature of this work is time-consuming, the program saves an estimated $1.3 million per year due to averted medication errors.

… Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the … in real time. The incidence of errors was higher than in a previous study , which used retrospective methods to detect …