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Self-reported uptake of recommendations after dissemination of medication incident alerts
  1. Ka-Chun Cheung1,
  2. Michel Wensing1,
  3. Marcel L Bouvy2,
  4. Peter A G M De Smet1,
  5. Patricia M L A van den Bemt3
  1. 1IQ Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
  2. 2Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
  3. 3Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
  1. Correspondence to Ka-Chun Cheung, Beroepsontwikkeling, Royal Dutch Pharmacists Association, Alexanderstraat 11, 2514 JL Den Haag, The Netherlands; k.c.cheung{at}


Introduction In the Netherlands, a Central Medication Incidents Registration (CMR) system is operational. To prevent recurrence of reported medication incidents the CMR sends medication incident alerts with recommendations. It is up to the healthcare workers whether or not to implement the recommendations in clinical practice, which may lead to variations in degrees of uptake of the recommendations.

Objective The aim of this study was to explore the degree of self-reported uptake of the recommendations and to identify potential determinants associated with successful uptake.

Design This is a cross-sectional study conducted within a convenience sample of 33 Dutch hospital pharmacies. The study was carried out from April 2009 to September 2010.

Measurements Three alerts were selected for the study: administration of methotrexate in a dosage of once a day instead of once a week, administration of undiluted potassium-sodium-phosphate concentrate, and administration of glucose 50% instead of 5%. The primary outcome was the degree of self-reported uptake of the specific recommendations and the associations of the degree of uptake with several potential determinants.

Results Twenty-one hospitals (63.6%) had adopted all recommendations about methotrexate. A quarter of the hospitals (24.2%) had adopted all recommendations related to potassium-sodium-phosphate concentrate. For the alert about glucose 50%, none of the hospitals had implemented all the recommendations. No statistically significant associations between potential determinants and the degree of uptake were found.

Conclusions This study is the first to investigate the degree of uptake of the recommendations of three different CMR alerts. The alerts varied in the degrees of self-reported uptake of the recommendations, with the methotrexate alert having the highest degree of uptake. No significant associations with potential determinants were found.

  • Implementation science
  • medication safety
  • clinical practice guideline
  • incident reporting
  • implementation science
  • medication safety
  • clinical practice guideline
  • incident reporting
  • healthcare quality improvement
  • human error
  • near miss
  • primary care
  • medication reconciliation
  • pharmacists
  • pharmacoepidemiology

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.