All Content

The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.

Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

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.

Successful development of a just culture centers on understanding different types of flawed human behavior and designing effective organizational responses to these failures. This article compares human error, at-risk behavior, and reckless behavior to suggest systems design changes for patient safety programs to generate opportunities for improvement.  

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).

This Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that provide care to pediatric patients. The authors identify risks and provide recommendations to ensure safe care of children including optimizing technology, utilizing external resources, and ensuring a pediatric pharmacist is in place.

Hospitalized patients receiving anticoagulants such as warfarin are at high risk for adverse drug events, and reducing the incidence of such errors is one of the Joint Commission's 2008 National Patient Safety Goals. In this study, a hospital system instituted several patient safety measures, including an anticoagulation service and executive walk rounds, to target anticoagulant-related medication errors. The 3-year project resulted in a significant reduction in both bleeding and thrombotic episodes. A case of a warfarin-related adverse event is discussed in an AHRQ WebM&M commentary.

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).