Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Despite widespread implementation of computerized provider order entry (CPOE) for medication ordering, some orders may be submitted wholly or in part using the free-text field. This study analyzed CPOE orders that included medication information in the free text field. High-risk medications (e.g., insulin, heparin) were frequently mentioned and the most common expected action was to discontinue. Despite using the same CPOE software, there were wide variations between the six included hospitals in the rates of orders in free text and the types of medications mentioned.

Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

The authors analyzed 26,000 communication for non-medication orders (CNMOs, a type of free-text communication order used to communicate information that does not align with structured medication orders) and found that over 42% of non-medication orders contain medication information, which may result in delayed, missed or inaccurate medications.

Although health information technology has been shown to improve patient safety, problems with implementation and user interface design persist. Unintended consequences associated with the use of electronic health record (EHR) and computerized provider order entry (CPOE) systems remain a safety concern. Pediatric patients may be particularly vulnerable to medication errors associated with EHR usability. Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities and found that 5079 events were related to the EHR and medication. Of these, 3243 identified EHR usability as contributing to the event, 609 of which reached the patient. Incorrect dosing was the most common medication error detected across the three facilities. A previous WebM&M commentary highlighted the unintended consequences of CPOE.

The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … In this study, researchers queried …

… J Patient Saf … Physicians are known to underuse voluntary …

Family-centered rounding is a key patient engagement strategy for hospitalized children. In this cluster-randomized trial that included nearly 300 families, 2 pediatric inpatient services implemented a checklist to promote family-centered rounding and 2 services provided usual care. Through observation of video-recordings, investigators determined that teams who were given a checklist were more likely to ask families if they had questions and to read back provider orders for confirmation. Although families' perceptions of safety climate improved with checklist implementation, overall quality and safety ratings between the checklist and usual care groups were similar. This trial provides evidence that performing certain elements of the checklist, such as read back, can modestly enhance patient and family engagement.

… J Patient Saf … J Patient Saf … This human factors study examined how …

Despite the demonstrated success of technology in reducing medication errors, preventable adverse drug events remain a significant source of harm to patients. Researchers analyzed data on medication safety events in 2 ICUs at a medical center and found 1622 preventable adverse drug events among 624 patients. About one third of these events were related to electronic health record use, including duplicate orders.

… J Am Board Fam Med … J Am Board Fam Med … This observational study of 11 community …

This commentary relates how physician multitasking to update electronic health records during patient encounters may increase risk of errors and makes recommendations to address these issues, including using a team documentation model.

As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.

This human factors engineering study used direct observation to determine that nurses' decisions whether to interrupt other nurses' work depended on the reason, the potential consequences, and interpersonal factors.

This paper builds upon the Systems Engineering Initiative for Patient Safety (SEIPS) model, incorporating three novel concepts: configuration, engagement, and adaptation.

This ethnographic study used direct observation to characterize how users of an electronic health record compensated for perceived system deficiencies.

This commentary describes a model that combines work system and process redesign to promote human factors engineering as a patient safety improvement strategy.

This commentary describes a medication reconciliation improvement toolkit, along with results and lessons learned from implementing the strategy.