This commentary describes best practices for safe medication use and how to integrate them into daily care delivery.

A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.

This commentary discusses how surgical care practitioners can protect patients from medication-related errors.

Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.

This study found that diuretics and antihypertensives were the most frequent medications reported in pediatric errors, and improper dosing was the most common type of administration error. However, error severity did not differ significantly by age or medication type.

This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.

This study describes characteristics associated with various tubing- and catheter-related errors, and advocates for educational opportunities to teach prevention strategies.

Analysis of MEDMARX data found that computerized systems did not prevent errors associated with dispensing and administering medications.

Medication errors associated with patient-controlled analgesia (PCA) are common and costly, according to this analysis of MEDMARX data. An AHRQ WebM&M commentary discusses a serious adverse drug event in a postoperative patient receiving PCA.

This study used MEDMARX data to characterize medication errors in the prescribing of medications for the treatment of attention deficit hyperactivity disorder. Most errors were detected by pharmacists and were committed at the prescribing stage.

Based on reports received through numerous national organizations, this article provides public policy recommendations for preventing certain tubing misconnections.

This article describes factors contributing to errors in enteral nutrition delivery and offers strategies to prevent medical tubing misconnections.

This commentary describes how one medical center developed a medication reconciliation program involving a multidisciplinary team.

The use of patient-controlled analgesia (PCA) is an important method to treat pain, but concerns about its safety and device selection have been raised. This study examined nearly 10,000 PCA-related medication errors submitted to MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that patient harm was associated with 6.5% of the errors, and the errors overall were reported across all phases of the medication process. The most common errors were related to improper dosage or quantity. An AHRQ WebM&M commentary discusses a case of a PCA overdose and the mechanisms to promote its safe use.

This study describes medication error types that occur in “code” situations and also highlights their impact on other patients (referred to as “collateral damage errors” by the authors). Using data from MEDMARX, a voluntary reporting database that tracks medication information from participating hospitals, investigators evaluated more than 2000 code-related errors. Omission errors were the most common error type, registered nurses and respiratory therapists were most frequently involved (though also the most likely to prevent errors), and anti-asthma/bronchodilator medications were the most common therapeutic class implicated. The authors provide a number of anecdotes to illustrate the relationship of the errors to the code situation, and detail the level of harm and common contributing factors reported. Finally, a series of preventive strategies are offered to reduce code-related medication errors, including redundant staffing to prevent collateral damage errors, and the use of DNR identification systems and rapid response systems to reduce code frequency.

Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.

Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.

Although adverse drug events (ADEs) are relatively frequent in outpatient chemotherapy, little is known about ADE rates in pediatric cancer patients. This study examined data from the Medmarx voluntary reporting system to characterize the frequency and severity of such errors in pediatric patients. More than 300 errors were reported over the 5-year study period, approximately 15% of which resulted in clinical consequences (ie, the need for additional patient monitoring or therapeutic intervention). Errors in administering medications were the most common cause of adverse events, as noted in a previous study. The authors note that these errors probably would not be prevented by safety interventions such as computerized physician order entry.

The authors share case reports that demonstrate how bar-code medication administration (BCMA) systems prevented errors in some cases but caused them in others.