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Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87(11):4150-4172.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21(1):648.
Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11(11):CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21(7):618.
Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43(5):1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11(10):e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6(4):e436.
The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common. 
Breuker C, Macioce V, Mura T, et al. J Patient Saf. 2021;17(7):e645-e652.
In this prospective observational study, hospital pharmacy staff obtained the best possible medication history for adult patients at admission to and discharge from one French hospital. Unintended medication discrepancies were identified in nearly 30% of patients. Most medication errors were omissions and risk of error increased with the number of medications.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
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.
Montaleytang M, Correard F, Spiteri C, et al. Int J Clin Pharm. 2021;43(5):1183-1190.
Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.
Ceschi A, Noseda R, Pironi M, et al. JAMA Netw Open. 2021;4(9):e2124672.
Medication reconciliation at hospital discharge can result in reduction of adverse events when the patient returns to the community. This study measured the effect of medication reconciliation performed at admission to hospital on subsequent health care outcomes. For patients ages 85 years and older, taking more than 10 medications at hospital admission, or both, medication reconciliation at admission did not have an impact on 30-day readmission to hospital.

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.

Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Res Social Adm Pharm. 2021;17(8):1426-1432.
This multicenter prospective study explored the effect of medication reconciliation on patient-reported, potential adverse events post-discharge. Although the intervention – which consisted of a pharmacy team providing patient both education and medication review upon admission and discharge as well as information transfer to primary care – did not decrease the proportion of patients with adverse events, it did reduce the number of potential adverse events.

ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital. Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using videoconferencing technology. The innovation has successfully reduced patient readmission and SNF length of stay.

Nanji K. UpToDate. Aug 11, 2021.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17(5):341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2(1):63.
Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.