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Interviews with clinicians who committed medication errors helped to identify contributing factors, which included understaffing and lack of access to prescribing information at the point of care.

This study noted two adverse drug events (ADEs) per 100 patient admissions in hospitalized cardiac patients. Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents and anticoagulants were the most common drug classes involved. Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between nurses at shift change. The authors advocate for prevention strategies around medication administration and nursing shift changes to reduce the potential for errors.

The authors implemented technologies supporting safe medication use and observed improved patient identification, decreased turnaround time for orders, and increased accuracy of medication administration.

This survey of pharmacy technicians identified interruptions and insufficent staffing as sources of errors.