The American Geriatrics Society (AGS) Beers Criteria serves as a guideline for prescribers to avoid potentially inappropriate medications (PIM) in geriatric patients (age 65 years and older). In this retrospective cohort study, nearly 70% of geriatric patients undergoing elective surgery received at least one PIM identified by the Beers Criteria. Patients, including cognitively impaired and frail patients, who received at least one PIM, had longer length of hospital stay after surgery.

In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.

Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.

Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.

Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.

The best possible medication history (BPMH) is the gold standard of medication reconciliation of a patient’s prescribed and over-the-counter medications. In this study, Certified Pharmacy Technicians (CPhTs) obtained BPMH from patients admitted through the emergency department. In Quality Assurance reviews, the CPhTs identified medication discrepancies at a similar rate to pharmacists, indicating that CPhTs may be a cost-effective alternative to pharmacists in obtaining BPMH.

Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 

Prior research has found that children with intellectual or developmental disabilities (IDD) may experience poor quality care and are at risk for adverse events, but less is known about risk among adults with IDD. Using data from a nationally representative database, the authors compared hospitalizations due to adverse medication events among adults with IDD compared with the general adult population and found that adults with IDD were at a significantly greater risk of having a hospital admission due to an adverse event (odds ratio, 1.28).

The vast majority of medication errors among geriatric patients at a university hospital were preventable. Factors predicting medication errors included patient factors, medication factors (i.e., polypharmacy), and systems factors (i.e., nurse staffing changes).