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PSNet: Patient Safety Network
Journal Article

Effects of patient-, environment- and medication-related factors on high-alert medication incidents.

Manias E, Williams A, Liew D, et al. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2014;26:308-20.

This retrospective chart review sought to identify medication errors related to high-alert medications in inpatient settings. High-alert medications include opioids, insulin, chemotherapeutic agents, parenteral electrolytes, and anticoagulants. The study found approximately 27% of high-alert medication uses had errors, with more occurring in the prescribing than the administration phase. Such medication incidents arose more often in patients who were transferred from one hospital ward to another, indicating that handoffs may play a role in safe use of high-risk medications. A recent AHRQ WebM&M commentary discusses erroneous inpatient dosing of anticoagulant medication over multiple work shifts.