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- Error Reporting and Analysis 1
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- Medication Errors/Preventable Adverse Drug Events
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Journal Article > Study
Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.
This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.
Crocker C. Nurs Times. 2009 Nov 24;105:12-15.
This article tracks the care of a United Kingdom National Health Service patient and identifies several areas for process improvement to ensure safe medication delivery.
Journal Article > Commentary
Trivedi A, Sharma S, Ajitsaria R, Davey NJ. Arch Dis Child Educ Pract Ed. 2019 May 9; [Epub ahead of print].
Medication reconciliation to ensure accuracy of patient medication lists has been difficult to implement. This project report describes an initiative to enhance the timeliness of medication reconciliation for pediatric inpatients. Use of Plan-Do-Study-Act cycles helped inform the evolution of the work. The authors emphasize the importance of engaging the entire care team as well as patients and families to enable completion of the process.
Journal Article > Study
Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story.
Botros S, Dunn J. BMJ Open Qual. 2019;8:e000363.
A quality improvement program that used a paper-based reminder to encourage physicians to complete medication reconciliation and communicate medication changes to outpatient physicians effectively improved the accuracy of medication reconciliation at discharge in a Scottish teaching hospital's surgical ward. The intervention was successfully disseminated to other wards within the hospital.