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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.

Association of hospital public quality reporting with electronic health record medication safety performance.

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Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4:e2125173.

Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.

Opioid prescribing to US children and young adults in 2019.

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Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.

Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

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Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.

Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

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Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;28:1791-1795.

Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.

Interventions to reduce pediatric prescribing errors in professional healthcare settings: a systematic review of the last decade.

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Koeck JA, Young NJ, Kontny U, et al. Pediatric Drugs. 2021;23:223-240.

Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).

Hyponatremia Secondary to Home Parenteral Nutrition Error

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May 26, 2021

A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate.

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

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Cerqueira O, Gill M, Swar B, et al. BMJ Qual Saf. 2021;30:1038-1046.

Computerized prescriber order entry (CPOE) systems embedded in electronic health systems alert clinicians to potential safety concerns such as drug-drug interactions or medication dosage errors. Results of this review indicate that alerts influenced prescriber behavior in most of the included studies. However, it is unclear whether these behavioral changes improve patient safety outcomes. Recommendations for future research include randomized controlled trials to determine which alerts maximize patient safety, while minimizing prescribers’ alert fatigue.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

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Srinivasamurthy SK, Ashokkumar R, Kodidela S, et al. Eur J Clin Pharmacol. 2021;77:1123-1131.

Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned.

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Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12:153-163.

Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.

Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review.

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Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.

Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

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Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Alert fatigue is a recognized contributor to task burden and medical error. This report distilled monitoring, analysis, and optimization experiences to recommend strategies for improving the effectiveness of clinical audible alerts which includes the development of an overarching clinical decision support governance plan.

Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study.

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Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20:506.

Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

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Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.

Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.

Risk factors associated with medication ordering errors.

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Abraham J, Galanter WL, Touchette DR, et al. J Am Med Inform Assoc. 2021;18:86-94.

Computerized provider order entry (CPOE) can prevent prescribing errors. In this study, researchers assessed voided medication orders to characterize medication ordering errors. Duplicate orders and improperly composed (wrong route, dose, strength, schedule) orders were most common and three-quarters were intercepted prior to administration. Risk factors for medication errors were multifactorial, arising from technological, cognitive, environmental, social, and organizational-level factors.

Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial.

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Delvaux N, Piessens V, Burghgraeve TD, et al. Implement Sci. 2020;15:100.

Clinical decision support systems (CDSS) and computerized physician order entry (CPOE) have the potential to improve patient safety. This randomized trial evaluated the impact of integrating CDSS into CPOE among general practitioners in Belgium. The intervention improved appropriateness and decreased volume of laboratory test ordering and did not show any increases in diagnostic errors.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis.

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Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28:167-176.

Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.

Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context.

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Drago K, Sharpe J, De Lima B, et al. J Am Geriatrics Soc. 2020;68:2123-2127.

Medications, particularly those with significant side effects, may be considered inappropriate for prescribing in elderly patients and can result in adverse outcomes.This study examined the impact of an automated electronic health record (EHR)-based support tool on potentially inappropriate medication doses in hospitalized elderly adults (age 75 and above) prescribed medications with geriatric-specific dose consideration. Among commonly ordered medications (such as antipsychotics, opioid- and non-opioid pain relievers, sleep agents, and anticholinergics), the support tool helped align drug doses for older adults and reduced total daily dose and average dose.

When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication

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October 28, 2020

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.

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

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Corny J, Rajkumar A, Martin O, et al. J Am Med Inform Assoc. 2020;27:1695–1704.

Machine learning can improve the accuracy of clinical decision support (CDS) tools. This single-site study used data from the electronic health record (EHR) and clinical pharmacist review to test the accuracy of a hybrid CDS system to identify prescriptions with high risk of medication error. The machine-learning based approach was more accurate than existing techniques such as the traditional CDS system and can improve the reliability of prescription checks in an inpatient setting.

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