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Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
Journal Article > Study
Nassaralla CL, Naessens JM, Hunt VL, et al. Qual Saf Health Care. 2009;18:402-407.
Accomplishing medication reconciliation has proven to be a difficult task in the ambulatory setting. Conducted in four academic primary care clinics, this study targeted medication reconciliation through a multifaceted intervention involving patient engagement as well as training and performance feedback for staff members. Although medication list completion and accuracy both improved significantly, half of medication lists remained incomplete after the intervention, and the majority contained errors. In view of the lack of proven strategies for improvement, The Joint Commission no longer formally scores medication reconciliation during on-site accreditation surveys (although it remains a National Patient Safety Goal).