This retrospective review examined more than 50,000 hospital admissions using two triggers—INR level and use of naloxone (an opioid reversal drug)—to determine whether these criteria improved detection of adverse drug events.

This study developed and tested an algorithm to optimize decision support and minimize alert fatigue during prescribing activities.

Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.

Although computerized provider order entry is being widely implemented to prevent medication errors, a significant proportion of errors are not due to incorrect prescribing, but instead occur at the drug administration stage. This study sought to estimate the error rate associated with each stage of the intravenous medication administration process and identify effective error prevention strategies. Prior research has investigated the use of smart infusion pumps, bar coding, and nursing education to prevent medication administration errors.

… J R Soc Med … J R Soc Med … The authors reviewed the literature … due to errors, not deliberately inappropriate actions. … Ferner RE, McDowell SE. Doctors charged with manslaughter in the course …