Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.

Systems thinking has been applied to address various underlying conditions that contribute to medical errors. This commentary discusses factors that affect patient medication nonadherence and suggests that a systems thinking approach can enable reliable patient use of prescription medications.

The large surge in opioid use is a serious patient safety problem. This retrospective study revealed that risk of postoperative inpatient opioid overdose increased over time. Patients with a substance abuse history were more likely to experience a postoperative opioid overdose, but hospital characteristics did not predict this complication. This finding suggests that high-risk patient characteristics should be taken into account in prescribing opioids after surgery.

Medication discrepancies between hospital and outpatient regimens can contribute to adverse events following hospital discharge. Pharmacist involvement in medication reconciliation is known to improve medication accuracy and reduce adverse drug events. This modeling study examined how implementing pharmacist-led medication reconciliation at hospital discharge affects a hospital payer's costs. Investigators calculated that an intervention that reduced medication discrepancies by 10% would be cost neutral. If pharmacist-led medication reconciliation improves accuracy as much as prior studies suggest, then implementing this process at hospital discharge should save costs. A past WebM&M commentary described a medication discrepancy that led to an adverse drug event.

Electronic health records (EHRs) were promoted as a patient safety improvement strategy, but their promise has not been fully realized. Comparing data from an EHR to information from insurance claims, this study found that EHRs inadequately capture mental health care, including inpatient and outpatient visits, medications, and specialty care. This information gap carries significant risk to patients and suggests a need for improved care integration and EHR interoperability.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This cohort study examined treatment patterns for patients who had experienced a nonfatal opioid overdose. More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17% of those patients experienced another overdose event. An accompanying editorial notes the lack of systems to ensure clinicians' awareness of patients' opioid overdoses and recommends enhancing training and support so that clinicians are prepared to treat chronic pain and addiction. New approaches are urgently needed given this crisis in medication safety. A previous WebM&M commentary discussed the challenges of prescribing safely for chronic opioid users.

Inappropriate antibiotic use contributes to microbial resistance for the recipient and the community. This study found increased harms related to antibiotic use among older patients living in nursing homes with higher antibiotic use compared to nursing homes with overall lower antibiotic use. These findings demonstrate the need to manage antibiotics effectively to improve the safety of all nursing home residents.

Preventing hospital readmissions has been a major health system priority for several years. Although recent data indicates that readmissions in adult patients are decreasing slightly, the approaches individual hospitals or health systems should use to prevent readmissions remain unclear. This randomized controlled trial evaluated the effect of a postdischarge virtual ward where patients received postdischarge care from a multidisciplinary team that met daily to review the patient's progress, conduct home visits, arrange home services, and coordinate care with the patient's primary physicians. Patients were admitted to the virtual ward for a mean of 35 days after discharge and received 3 home visits on average during that time. Despite the intensity of the intervention, there was no effect on 30-day readmissions or any other clinical outcome compared to usual postdischarge care. Another recent randomized trial found that a similarly intensive intervention did not reduce readmissions in a vulnerable elderly patient population. The authors of this study note that difficulty in communicating with primary care physicians, exacerbated by the lack of an integrated electronic medical record, may have contributed to the failure of the virtual ward at preventing readmissions.

In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.

This study suggests that diagnostic coding error may significantly underestimate the costs associated with adverse events.

Part of the Users' Guides to the Medical Literature series, this article discusses quality improvement research methods and explains how to assess the effectiveness of results published in this field.

This study discovered variability in pharmacists' interpretation of physician prescriptions, raising concerns about the consistency of information provided to patients about safe medication use.

Although nearly one-third of deaths after bypass surgery were judged to be preventable based on retrospective review, preventable deaths were not correlated with individual hospital risk-adjusted mortality rates.

This study used direct observation of pharmacists and other health care professionals involved in preparing intravenous drug infusions to estimate the incidence and types of medication errors committed while preparing infusions.

This randomized study found that academic detailing yielded modest impact on appropriate monitoring of patients started on selected high-risk medications. A past study also demonstrated limited success with academic detailing as a sole intervention to promote medication safety.

Pharmacy-issued medication containers frequently did not highlight instructions or consistently use warning labels. Labels also varied considerably between different pharmacies.

This study demonstrated that replacing drug-specific alerts with age-specific ones sustained (but did not enhance) previously noted decreases in inappropriate prescribing with drug-specific alerts alone. Investigators conducted a cluster-randomized trial of seven practices that received age-specific alerts in addition to academic detailing with eight practices that received only the alerts. The academic detailing process involved an interactive educational program to assist with alternative and evidence-based medication choices. Findings suggested that clinical decision support can be effective using alert systems, but improvements in tools such as academic detailing are needed, as the process had no benefit in this study. Shifting to age-specific alerts did decrease the alert burden overall to providers. A past review discussed the issue of inappropriate prescribing in the elderly while other studies evaluated its prevalence in outpatient settings and elderly veterans.

The authors evaluated the effectiveness of computerized alerts in reducing co-prescribing of warfarin and interacting medications. They found that the alerts had a modest impact on minimizing this potentially dangerous behavior.

This AHRQ–funded study discovered that the use of alerts within an electronic medical record system can reduce the number of unsafe medications prescribed in elderly outpatients. Investigators evaluated the impact of a clinical decision support system (CDSS) at the point of computerized provider order entry (CPOE), targeting two classes of contraindicated medications (long-acting benzodiazepines and tertiary amine tricyclic antidepressants). The authors discuss the rapid, significant, and persistent reductions in medication prescribing of these high-risk medications, suggesting the effectiveness of an alert system to curtail inappropriate prescribing. This study is a first to evaluate a computerized alert system in a large population-based primary care setting, although a past systematic review evaluated the effects of CDSS on practitioner performance and patient outcomes.

This population-based study examined how adverse bleeding events associated with warfarin affected physicians' prescribing the drug to other patients.