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Medication safety issues with newly authorized PAXLOVID.

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Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using reason's accident causation theory.

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Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43:1693-1704.

While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.

Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products

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Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.

Reducing medication errors for adults in hospital settings.

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Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11:CD009985.

Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.

Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.

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Wallis KA, Elley CR, Moyes SA, et al. BJGP Open. 2022;6:BJGPO.2021.0129.

Common high-risk medications such as antiplatelets and non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to cause serious patient harm. This randomized trial examined the usefulness of an existing intervention to support safer prescribing in general practice to improve safe high-risk prescribing.

Age-related COVID-19 vaccine mix-ups.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Factors influencing providers' willingness to deprescribe medications.

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Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.

Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

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Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.

This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

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Chaker A, Omair I, Mohamed WH, et al. Am J Health Syst Pharm. 2022;79:187–192.

The Institute for Safe Medication Practices recommends compounding pharmacies use technology and automation to improve patient safety. Researchers assessed the workflow and workforce requirements of one hospital’s sterile preparation center (SPC) following implementation of these recommendations. The average time to prepare each type of medication was used to determine pharmacy staffing workforce requirements.

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

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Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.

This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.

Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.

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Chauhan A, Walpola RL. Int J Qual Health Care. 2021;33:mzab145.

Health care decision making and delivery are vulnerable to unconscious bias. This commentary discusses strategies in place to address unconscious bias as it affects medication safety. The authors suggest a focus on engaging ethnic minority consumers as partners to design improvement programs to enhance medication delivery.

Prevent errors during emergency use of hypertonic sodium chloride solutions.

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ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.

Delays in diagnosis and treatment during life-threatening emergencies such as strokes can result in irreversible patient harm. This article discusses a variety of factors contributing to errors in administering hypertonic sodium chloride in emergent situations. The piece shares recommendations touching on various elements of the medication delivery process to enhance safety.

Clinically significant medication errors in surgical units detected by clinical pharmacist: a real-life study.

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Renaudin P, Coste A, Audurier Y, et al. Basic Clin Pharmacol Toxicol. 2021;129:504-509.

Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.

Deprescribing as a Patient Safety Strategy

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October 27, 2021

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

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October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study.

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Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11:e054364.

Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.

Quantifying discharge medication reconciliation errors at 2 pediatric hospitals.

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Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6:e436.

The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common.

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

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Moureaud C, Hertig JB, Dong Y, et al. Health Policy (New York). 2021;125:1421-1429.

Based on survey responses from 1,002 participants, this study evaluated how social media users assess, interact and engage with information related to the illegal sales of prescription medicines. Findings suggest that individuals generally perceive online pharmacies and social media platforms to be safe and respondents are confident in their ability to acquire legitimate medicines. The authors note that this false confidence has the potential to lead to patient harm given the prevalence of counterfeit and substandard medication available on these platforms.

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