Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51:520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.
Contreras J, Baus C, Brandt C, et al. J Am Pharm Assoc (2003). 2021;61:e94-e99.
Naloxone administration is used to mitigate the effects of opioid overdose. The FDA recommends health care professionals educate patients about naloxone when prescribing opioid medications. In this audit of community pharmacists, researchers found that naloxone counseling commonly often excluded concepts important to patient safety, such as assessment of opioid misuse or abuse, possible adverse effects, and naloxone storage.
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.
Alqenae FA, Steinke DT, Keers RN. Drug Saf. 2020;43:517-537.
This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.
Sunkara PR, Islam T, Bose A, et al. BMJ Qual Saf. 2020;29:569-575.
This study explored the influence of structured interdisciplinary bedside rounding (SIBR) on readmissions and length of stay. Compared to the control group, the odds of 7-day readmission were lower among patients admitted to a unit with SIBR (odds ratio=0.70); the intervention did not reduce length of stay or 30-day readmissions.
Balsom C, Pittman N, King R, et al. Int J Clin Pharm. 2020:Epub Jun 3.
Polypharmacy is one risk factor for medication errors in older adults. This study describes the implementation of a pharmacist-administered deprescribing program in a long-term care facility in Canada. Over a one-year period, residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. The intervention resulted in fewer medications taken by residents the intervention group after 6 months. Most deprescribing recommendations reflected a lack of ongoing indication or a dosage that was too high.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Jacobs S, Hann M, Bradley F, et al. Res Soc Admin Pharm. 2020;16:895-903.
This study evaluated cross-sectional survey data from pharmacists and patients to characterize organizational factors associated with variation in safety climate, patient satisfaction and self-reported medication adherence in community pharmacies in the United Kingdom. Safety climate was associated with pharmacy ownership, organizational culture, working hours, and employment of accuracy checkers. Skill mix and continuity of care also influenced safety culture and quality.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Pfeiffer Y, Zimmermann C, Schwappach DLB. BMJ Qual Saf. 2020;29:536-540.
Double checking is one strategy for detecting and preventing medication errors; however, its effectiveness is unclear. This editorial presents a framework intended to further research and clinical practice by defining and classifying checking procedures and differentiating them from other medication-related safety behaviors.
Keers RN, Hann M, Alshehri GH, et al. PLoS One. 2020;15:e0228868.
This study described medication omission errors occurring in inpatient mental health hospitals in the United Kingdom. Of over 18,000 scheduled medication doses, 2,700 omissions were identified (omission rate, 14.6%). One-third of all omissions were considered ‘preventable.’ The omission rate among ‘time critical’ medications (those that carry risk of harm if a single dose is omitted) was 19.3%, and half of these omissions were considered ‘preventable’. Predictors of omission errors are discussed, including administration route and medication type. Analyses found that administration route, medication class and time of medication administration rounds were significantly associated with omission errors. These findings should inform future research and quality improvement initiatives designed to reduce the burden of omission errors in psychiatric hospitals.
Presley CA, Wooldridge KT, Byerly SH, et al. Am J Health Syst Pharm. 2020;77:128-137.
This article reports mixed results of a two-year mentor-implemented feasibility study designed to improve medication reconciliation practices in rural Veterans Affairs hospitals. The authors highlight facilitators and barriers to implementing their evidence-based intervention in smaller hospitals.
Hong K, Hong YD, Cooke CE. Res Social Adm Pharm. 2019;15:823-826.
Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.
Falconer N, Barras M, Martin J, et al. Eur J Clin Pharmacol. 2019;75:137-145.
Lack of clarity around language used to discuss patient safety concepts hinders effective monitoring and measurement of errors and their impact. This narrative review examined the various terms used to discuss medication-related harm. The authors advocate for development of standard definitions and terms for use in medication error research, policy development, and improvement efforts.
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