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.

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.

… , the Veterans Affairs (VA) health care system has had a fully electronic health record with computerized provider …

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 …