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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.

Aldila F, Walpola RL. Res Social Adm Pharm. 2021;17:1877-1886.
Older adults are at increased risk of medicine self-administration errors (MSEs) due to polypharmacy, cognitive decline, and decline in physical abilities. In this review, incorrect dosing was the most common MSE; the most common factor influencing the errors is complex medication regimens due to the need for multiple medications. Additional research is needed into how community pharmacists can assist older adults at risk of MSE.
Cataldo RRV, Manaças LAR, Figueira PHM, et al. J Oncol Pharm Pract. 2022;28:884-891.
Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Bookwalter CM. US Pharmacist. 2021;46(2):25-28. 

 

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.

A 58-year-old female receiving treatment for transformed lymphoma was admitted to the intensive care unit (ICU) with E. coli bacteremia and colitis secondary to neutropenia, and ongoing hiccups lasting more than 48 hours. She was prescribed thioridazine 10 mg twice daily for the hiccups and received four doses without resolution; the dose was then increased to 15 mg and again to 25 mg without resolution.

Pedersen CA, Schneider PJ, Ganio MC, et al. Am J Health Syst Pharm. 2020;77:1026-1050.
This article describes results from the 2019 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. The authors note the increasing responsibilities placed on pharmacists and their role in addressing the opioid crisis, adopting intravenous workflow technologies, and leveraging clinical decision support tools to improve medication administration safety.
Goldberg EM, Marks SJ, Merchant RC, et al. Acad Emerg Med. 2021;28:248-252.
This analysis found that only 23% of older adults in the Emergency Department had complete agreement between self-reported medications and pharmacy dispensing records. Over half of patients omitted antibiotics from self-report, which can result in adverse events, as antibiotics can have potentially fatal interactions with many medications.
Nguyen AD, Lam A, Banakh I, et al. J Pharm Pract. 2020;33:299-305.
This study evaluated the impact of the PeRiopErative and Prescribing (PREP) pharmacist, who is responsible for obtaining the best possible medication history and preparing discharge prescriptions. Results indicate that the inclusion of the PREP pharmacist on the multidisciplinary surgical team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for high-risk patients.
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended.
Am J Health-Syst Pharm. 2020;77:308-312.
This piece highlights the value of a medication safety leader in guiding error prevention efforts and outlines the responsibilities of such a role. Areas of focus include leadership, medication safety expertise, change management, research and education.
This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20:481-490.
The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Lapointe-Shaw L, Bell CM, Austin PC, et al. BMJ Qual Saf. 2020;29:41-51.
Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.
Wiley F. Drug Topics. August 2019;1633:16-18.
High-alert medications have the potential to cause serious patient harm if not administered correctly. Reporting on challenges to medication safety in the context of home, hospital, and cancer care, this news article recommends patient and health care professional education and support for collaboration with pharmacists as avenues for improvement.