Sutherland A, Ashcroft DM, Phipps DL. Arch Dis Child. 2019;104:588-595.
Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.
Harbaugh CM, Lee JS, Chua K-P, et al. JAMA Surg. 2019;154:e185838.
This retrospective cohort study found that adolescent patients who received opioids for surgical and dental procedures were more likely to develop persistent opioid use if they had family members with long-term opioid use. The study team recommends preoperative screening for long-term opioid use in family members as part of prescribing decision-making for adolescent patients.
Rollman JE, Heyward J, Olson L, et al. JAMA. 2019;321:676-685.
Researchers assessed the effectiveness of the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy in preventing inappropriate prescribing of transmucosal immediate-release fentanyl, high-risk opioid products with narrow prescribing indications. Survey data obtained from patients, providers, and pharmacists at various points after the FDA program's initiation suggested ongoing misunderstanding regarding appropriate prescribing. Analysis of claims data 5 years into the program revealed that anywhere from 35% to 55% of patients were prescribed transmucosal immediate-release fentanyl products inappropriately.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Health Aff (Millwood). 2018;37:1813-1820.
Patient and family engagement efforts can affect health care quality and safety. This review examined the research on patient engagement efforts and found evidence of robust examinations of patient engagement related to patient self-management of anticoagulation medications. However, there was mixed-quality evidence on patient involvement in medication administration errors, documentation and scheduling accuracy, hospital readmissions, and health care–associated infections. They recommend areas of research needed to guide the application of patient engagement strategies.
Ratwani RM, Savage E, Will A, et al. Health Aff (Millwood). 2018;37:1752-1759.
Although health information technology has been shown to improve patient safety, problems with implementation and user interface design persist. Unintended consequences associated with the use of electronic health record (EHR) and computerized provider order entry (CPOE) systems remain a safety concern. Pediatric patients may be particularly vulnerable to medication errors associated with EHR usability. Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities and found that 5079 events were related to the EHR and medication. Of these, 3243 identified EHR usability as contributing to the event, 609 of which reached the patient. Incorrect dosing was the most common medication error detected across the three facilities. A previous WebM&M commentary highlighted the unintended consequences of CPOE.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Opioid deaths are a major public health and patient safety hazard. This multimodal, health care system-level intervention to reduce opioid overprescribing consisted of changes to the electronic health record, patient education, and provider education and oversight. Opioid prescribing decreased substantially (58%) systemwide with no discernible decrement in patient satisfaction.
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. J Eval Clin Pract. 2019;25:28-35.
Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.
Wong A, Plasek JM, Montecalvo SP, et al. Pharmacotherapy. 2018;38:822-841.
Natural language processing (NLP) can efficiently analyze large narrative data sets to identify adverse events. Exploring the application of NLP to reduce medication errors, this AHRQ-funded review describes challenges associated with using NLP to extract information from clinical sources and highlights how engaging pharmacists in developing NLP systems can improve medication safety.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Gates PJ, Meyerson SA, Baysari MT, et al. Pediatrics. 2018;142:e20180805.
Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.
Doctor JN, Nguyen A, Lev R, et al. Science (1979). 2018;361:588-590.
High-risk opioid prescribing by providers contributes to opioid misuse. Prior studies have shown that patients frequently receive opioid prescriptions even if they have a history of overdose. In this randomized trial involving 861 providers prescribing opioids to 170 patients who experienced fatal overdose, providers in the intervention arm were notified about patients' deaths by the county medical examiner while those in the control arm were not. Researchers found that milligram morphine equivalents prescribed to the patients of providers who received the death notifications decreased by almost 10% in the 3-month period following the intervention. There were no significant changes in the prescribing patterns of the control group. An Annual Perspective discussed patient safety and opioid medications.
Chung CP, Callahan T, Cooper WO, et al. Pediatrics. 2018;142:e20172156.
Reducing the incidence of opioid overdoses and overdose deaths is an essential patient safety priority. In the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays for opioid poisoning. Researchers examined outpatient opioid prescriptions to children who did not have serious illnesses like cancer or sickle cell disease in Tennessee between 1999 and 2014. Dentists prescribed the largest share of more than 1 million opioid prescriptions, followed by surgeons. The authors conclude that 1 in every 2611 prescriptions resulted in an emergency department visit or hospitalization. An accompanying editorial contextualizes the study findings and offers suggestions, such as relying on less toxic analgesics for dental procedures and choosing alternatives to codeine for children who need opioids. A past PSNet perspective examined the patient safety implications of the opioid epidemic.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
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